Background Total parenteral nutrition (TPN) as a traditional mode of treatment in severe acute pancreatitis was still used widely in clinical work. In addition, enteral nutrition treatment methods have developed; early enteral nutrition has already been highlighted for severe acute pancreatitis, but the therapeutic risks versus benefits need to be studied.
Aims and Objective To compare total parenteral nutrition with total enteral nutrition (TEN) in patients with severe acute pancreatitis by performing a meta-analysis.
Materials and Methods Electronic databases including PubMed, EMBASE, Science Citation Index, were searched to find relevant randomized controlled trials. Two reviewers independently identified relevant trials evaluating the effect of total parenteral nutrition and early enteral nutrion. Outcome measures were the mortality, hospital length of stay, infectious complications, duration of nutrition, organ failure and surgical intervention.
Results Eight randomized controlled trials (RCTs) including 381 patients were identified. Meta-analysis demonstrated that TEN was significantly superior to TPN when considering mortality [p=0.001, 95%CI 0.37(0.21-0.68)], infectious complications [p=0.004, 95%CI 0.46(0.27-0.78)], organ failure [p=0.02, 95%CI 0.44(0.22-0.88)] and surgical intervention [p=0.003, 95%CI 0.41(0.23-0.74)].While no difference between TEN and TPN when considering the hospital length of stay [p=0.22, 95%CI -14.10(-36.48-8.26)] and as for duration of nutrition [p=0.72, 95%CI -1.50(-9.56-6.56)] there was not enough data to compare the differences.
Conclusion Total enteral nutritional support is associated with lower mortality, fewer infectious complications, decreased organ failure and surgical intervention rate compared to parenteral nutritional support.

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Background Some studies have shown that antioxidant ascorbic acid has renal protective effects, but the beneficial effects of contrast-induced nephropathy prevention remain to be clearly shown. Therefore, we aimed to determine whether ascorbic acid pretreatment reduces the risk of contrast-induced nephropathy in a high-risk population of patients with renal insufficiency undergoing coronary angiography.
Methods We conducted a prospective, randomized, controlled trial, involving 156 consecutive patients with chronic renal insufficiency (calculated estimated glomerular filtration rate<60 mL/min/1.73 m² and/or serum creatinine≥1.1 mg/dL) undergoing coronary angiography. Patients were randomized to ascorbic acid (n=74, 3 g intravenous injection before the procedure and oral 1 g per day for 2 days after the procedure, ascorbic acid group) or sodium chloride alone (n=82, control group). All patients received pre-and postprocedure hydration.
Results There was no difference between the ascorbic acid group and control group in mean peak increase in serum creatinine measured within 48 hours after coronary angiography, the primary study end point (0.012±0.146 vs 0.022±0.212 mg/dL respectively, p=0.216). The incidence of contrast-induced nephropathy, a secondary end point defined as increase of either≥25% or≥0.5 mg/dL in serum creatinine, was 5.4% in ascorbic acid-treated patients (4/74) and 6.3% in control group patients (6/82), a nonsignificant difference (p=0.690). There were also no differences between the 2 groups in the inhospital clinical outcomes or length of hospital stay.
Conclusion Ascorbic acid pretreatment for short-term at high dose do not prevent renal function deterioration after administration of contrast medium in patients with baseline renal insufficiency undergoing coronary angiography.

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Objective The objective of the present multi-ethnic study was to explore whether an association exists between brachial-ankle pulse wave velocity (baPWV) and cardiovascular risk factors in China.
Methods Two hundred sixty-four adult subjects (152 subjects were of Han nationality, 70 subjects were from Uygur, 19 subjects were from Kazakh, 15 subjects were from Hui, and 8 subjects were of other nationalities.) aged 30-82 years were enrolled in the present study. The subjects' anthropometric, baPWV and laboratory measurements were recorded.
Results Age (p=0.000), systolic blood pressure (p=0.000), diastolic blood pressure (p=0.002), fasting blood glucose (p=0.000), and hemoglobin (p=0.019) differed significantly among the subjects in the baPWV quartile. Spearman correlation analyses indicated that baPWV was significantly and positively associated with age (r=0.584, p=0.000), systolic blood pressure (r=0.396, p=0.000), diastolic blood pressure (r=0.217, p=0.000), and fasting blood glucose (r=0.231, p=0.000). baPWV was significantly and negatively associated with erythrocyte number (r=-0.181, p=0.003) and hemoglobin (r=-0.192, p=0.002) levels. Multiple regression analyses suggested that age (β=0.573, p=0.000), systolic blood pressure (β=0.181, p=0.003), triglycerides (β=0.160, p=0.008), and cholesterol (β=0.132, p=0.020) were independently associated with baPWV.
Conclusion Age, SBP, triglycerides, and cholesterol levels are independently and positively associated with baPWV.

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Objective To identify metabolites showing changes in serum levels among Japanese male with diabetes.
Methods We performed metabolite profiling by coupling capillary electrophoresis with electrospray ionization time-of-flight mass spectrometry using fasting serum samples from Japanese male subjects with diabetes (n=17), impaired glucose tolerance (IGT; n=5) and normal glucose tolerance (NGT; n=14).
Results Other than the expected differences in characteristics related to abnormal glucose metabolism, the percent body fat was significantly different among subjects with diabetes, IGT and NGT (27.3±6.2, 22.2±4.5 and 19.2±6.0%, respectively, p=0.0022). Therefore, percent body fat was considered as a possible confounding factor in subsequent analyses. Of 560 metabolites detected using our platform, the levels of 74 metabolites were quantified in all of the serum samples. Significant differences between diabetes and NGT were observed for 24 metabolites. The top-ranked metabolite was glycerol-3-phophate (glycerophosphate), which was significantly higher in subjects with diabetes than in those with NGT, even after Bonferroni correction for multiple testing (11.7±3.6 vs. 6.4±1.9 μM, respectively; corrected p=0.0222). Stepwise multiple regression analyses revealed that serum glycerophosphate levels were significantly correlated with 2-h plasma glucose after a 75-g oral glucose tolerance test (r=0.553, p=0.0005), independently of other characteristics, including FPG and HbA1c.
Conclusion Serum glycerophosphate levels were found to be elevated in Japanese men with diabetes, and correlated with 2-h PG, independent of FPG and HbA1c. Namely, serum glycerophosphate level at fasting condition can be a marker for predicting glucose intolerance. These results warrant further studies to evaluate the relevance of glycerophosphate in the pathophysiology of diabetes.

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Objective Visfatin is a peptide that is secreted from visceral fat. It has been reported to be associated with inflammation and endothelial dysfunction. However, little is known about its function in hypertension. Therefore the aim of the present study was to evaluate visfatin levels in patients with hypertension.
Methods We studied forty-six newly diagnosed hypertensive patients and 30 healthy participants. In accordance with blood pressure levels reported in the JNC 7 guidelines, hypertensive patients were divided into 2 groups: stage 1 and stage 2. The control group was divided into 2 groups: normal and prehypertensive. Blood pressure (BP) measurements were obtained from each patient. Serum lipid profile, glucose and visfatin levels were measured.
Results The levels of fasting blood glucose (FBG), total cholesterol, triglyceride (TG), low density lipoprotein cholesterol (LDL-C), BMI, waist circumference were significantly higher in the patient group than those in control subjects (p<0.05). The mean visfatin level was significantly higher in hypertensive patients. In the prehypertensive group, the serum visfatin levels were also significantly higher than in participants with normal blood pressure (p:0.043). There was a significantly positive correlation with visfatin and systolic BP, diastolic BP.
Conclusion We consider that visfatin may be a marker which may be used to illustrate damage even in prehypertensive stage caused by isolated essential HT.

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Objective The role of oxidative stress in IgA nephropathy (IgAN), the most common type of primary glomerulonephritis, is unknown. We evaluated the clinical significance of serum levels of oxidative stress markers, thioredoxin (TRX) and manganese superoxide dismutase (MnSOD), in patients with IgAN.
Methods Forty-eight patients with histologically confirmed IgAN and 14 healthy subjects were enrolled in this study. Serum samples from 14 IgAN patients were obtained after tonsillectomy, a procedure hypothesized to be an effective treatment for IgAN.
Results Serum TRX levels were significantly higher in patients with IgAN than in healthy subjects (mean [ng/mL]; 49.5 vs.14.4, p<0.001). Serum TRX levels are positively correlated with blood urea nitrogen, serum uric acid and proteinuria, and negatively with estimated glomerular filtration rate (eGFR). In addition, serum TRX levels gradually increased as the severity of renal histology increased. High levels of serum TRX were significantly decreased after tonsillectomy in patients with IgAN (mean [ng/mL]; 55.5 to 41.1, p=0.02). In contrast, serum MnSOD levels did not differ between IgAN patients and healthy subjects, and these levels did not change after tonsillectomy in IgAN patients.
Conclusion Serum TRX is associated with IgAN, and tonsillectomy may decrease oxidative stress in IgAN patients, leading to clinical improvement.

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Background Despite the advances of asthma management and the accompanying improved asthma control, many problems related to asthma management still remain. The Niigata Asthma Treatment Study Group has been regularly collecting information via surveys since 1998 using a questionnaire, on problems related to asthma management; various studies on asthma management have been reported using data from the questionnaire.
Methods The aim of this study was to investigate the changes in asthma control and management for every two-year period using the data from 1998 to 2008; future problems requiring resolution were extracted and discussed.
Results The number of cases surveyed each year was about 3,000 (2,593-3,347 cases). The changes in the data from 1998 to 2008, including asthma attacks and symptoms rate, indicated the improvement of asthma control with the spread of medication according to the guidelines; of particular note, there was a 24.1% increase in the usage rate of inhaled corticosteroids during the study period. From 2002 to 2008, however, some asthmatic conditions seemed to show no improvement with regards to asthma control related to the rates of changes in peak flow meter use, leukotriene receptor antagonist use and oral sustained-released theophylline use. Moreover, there was no decrease in the occurrence of emergency episodes related to asthma deaths.
Conclusion In the actual clinical setting, asthma control seems to be progressing well with the appropriate changes of medication according to the guidelines, and in part due to inhaled corticosteroid use. However, there were two problems which need to be addressed: 1) no improvement in some asthmatic conditions and 2) the occurrence of emergency episodes related to asthma deaths. In the future, it will be necessary to manage asthma in view of these points.

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Objective Donepezil is a widely used cholinesterase inhibitor for the treatment of Alzheimer's disease (AD), however its cholinergic adverse side effects on the cardiovascular system are still unclear. In this study, we aimed to examine the adverse side effects caused by donepezil on cardiac rhythm and postural blood pressure changes in elderly patients with Alzheimer Disease.
Methods The ECG parameters including heart rate, PR, QT, QTc interval and QRS duration and postural blood pressure changes were recorded at the baseline and at each donepezil dose level (5 and 10 mg/d).
Patients Seventy-one consecutive patients who were referred by primary care centers to a Geriatric Clinic were enrolled and underwent comprehensive geriatric assessment.
Results Fifty-two subjects completed the study. There were no significant changes relative to the baseline in any of the ECG parameters or arterial blood pressure at any of the investigated dosages of donepezil.
Conclusion It was demonstrated that donepezil was not associated with increased negative chronotropic, arrhythmogenic or hypotensive effects for elderly patients with Alzheimer's disease.

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Objective The population in Japan is aging at a faster rate than in other countries in the world. It is speculated that the number of patients with late-onset amyotrophic lateral sclerosis (ALS) will increase even more in the future. However, few studies have been undertaken on the characteristics of patients with late-onset ALS in Japan. This study sought to investigate the clinical features of patients with late-onset ALS compared with those with early-onset ALS using the progression rate (ΔFS).
Methods Forty-five patients with sporadic ALS were divided into 2 groups: 23 patients with early-onset of ALS (<65 years; early onset) and 22 patients with late-onset ALS (≥65 years; late onset). Every patient was followed up from the time of initial diagnosis to the primary endpoint (death or time culminating in death without tracheostomy or ventilation assistance including noninvasive positive pressure ventilation) or for at least 48 months after initial diagnosis.
Results ΔFS in the patient group with late onset was significantly higher than that of the group with early onset (p=0.010). Survival of patients with late onset was significantly decreased compared to that of patients with early onset (p=0.031).
Conclusion Our finding suggested that patients with late-onset ALS showed more rapid disease progression than those with early-onset ALS using ΔFS.

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Objective The Japan Respiratory Society documented a new category of guidelines for nursing and healthcare-associated pneumonia (NHCAP), which is distinct from community acquired pneumonia (CAP). The objective of this study was to determine the epidemiological differences between NHCAP patients in a teaching university hospital and a community hospital. In addition, to clarify the strategy for treatment of NHCAP, we investigated the role of atypical pathogens.
Methods We analyzed 250 NHCAP and 421 CAP cases in a university hospital and 349 NHCAP and 374 CAP cases in a community hospital.
Results Patient age and the incidences of poor general condition were significantly higher in the community hospital compared with those in the university hospital. The distribution and frequency of pathogens, especially multidrug-resistant (MDR) pathogens, were significantly different between the two hospitals. Central nervous system disorders, dementia and poor performance status, which was possibility related to aspiration pneumonia, were significantly more frequent in patients with NHCAP compared with those with CAP in both hospitals. Atypical pathogens were detected in a few cases in patients with NHCAP.
Conclusion There were many differences in the clinical characteristics between NHCAP patients in a university hospital and a community hospital even for hospitals located in the same area. Aspiration pneumonia was thought to be the main characteristic of NHCAP in both hospitals. Thus, all NHCAP patients did not need the same empiric therapy with a multidrug regimen directed against MDR pathogens. In addition, physicians rarely need to consider atypical pathogens in NHCAP treatment.

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A 21-year-old Caucasian man with a diagnosis of Crohn's disease (CD) at the age of 14 was admitted to our hospital due to CD flare-up while under scheduled adalimumab (ADA) maintenance therapy. His symptoms remained virtually unchanged following high dose corticosteroid therapy. Seven days later, combination therapy with ADA plus intensive granulocyte/monocyte adsorptive apheresis (GMA) was initiated, which induced clinical remission. Therefore, combination therapy with ADA plus intensive GMA appears to be an effective therapeutic option for patients with severe CD while under scheduled ADA maintenance therapy.

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Warfarin is widely prescribed for patients with atrial fibrillation. In addition to unexpected bleeding, allergic skin reaction is one of its uncommon adverse effects. We herein report an 89-year-old man who, after taking warfarin for 4 years, suffered extensive skin eruptions. The skin biopsy disclosed leukocytoclastic vasculitis. The causal relationship between skin lesions and warfarin was confirmed after re-challenge of warfarin. A literature review revealed only 13 such cases reported from 1980 to 2011. Clinicians should be aware of this potential adverse effect of warfarin.

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An 81-year-old woman was admitted to our hospital with acute heart failure. A coronary stent was implanted in the left circumflex artery (LCX) on day 3, and elective percutaneous coronary intervention for stenosis in the left anterior descending artery (LAD) was planned for day 10. However, 15 minutes after heparin administration, sudden thrombotic occlusion occurred first in the LAD and then in the LCX. Although anti-platelet factor 4/heparin antibody positivity was detected, there was no significant decrease in platelet counts. This suggests that in the event of unexplained thrombosis, heparin-induced thrombosis should be suspected irrespective of platelet counts and early onset.

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Head and neck paragangliomas that are exclusively or predominantly dopamine-secreting are rare. Surgery and/or radiotherapy are modalities for locoregional tumoral control. Little is known about the efficacy of radiotherapy for biochemical control in such tumors. We report a 62-year-old Chinese man with bilateral carotid body tumors which were exclusively dopamine secreting. The left-sided tumor invaded the skull base and encased the left carotid artery. Surgery was not performed due to high risk of morbidity and mortality. The patient received external beam radiotherapy to bilateral neck regions. Progressive decline and eventual normalization of urinary dopamine excretion was seen together with a slight reduction in tumor size. This is the first report demonstrating the efficacy of radiotherapy for both biochemical and locoregional control of functioning carotid body paragangliomas.

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Although the appearance of abnormal lipoproteins in liver diseases is well known, the precise analyses of abnormal lipoproteins remain elusive. Here, we report a 71-year-old woman with type 2 diabetes whose serum cholesterol levels were elevated to 560 mg/dL over a 4-month period. High-performance liquid chromatography demonstrated the presence of lipoprotein-X and lipoprotein-Y and sigmoid colon cancer and multiple liver metastases were found by colonoscopy and computed tomography. Remission of the primary colon cancer and liver lesions was achieved by chemotherapy with oxaliplatin and fluorouracil and her serum cholesterol went back to basal levels associated with the disappearance of abnormal lipoproteins.

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Herein, we report a 37-year-old man presenting with nephrocalcinosis associated with primary aldosteronism. Primary hyperaldosteronism is reported to facilitate urinary calcium excretion; however, renal calculi or calcinosis in this disorder has been rarely reported. The patient had renal dysfunction and calcification in the renal medulla on both kidneys. A kidney biopsy was performed. His renal dysfunction seemed to be mainly caused by hypertension and tubulointerstitial damage. Furthermore, von Kossa-positive stones were seen in some tubules. X-ray element analysis revealed that the stones were composed of calcium phosphate.

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Epstein-Barr virus (EBV) infection is common in adolescence, but fulminant infection is very rare. A 40-year-old man presented with high fever and sore throat. Symptoms, including cervical lymphadenopathy, jaundice, atypical lymphocytosis, respiratory distress and oliguria, suggested infectious mononucleosis with multiple organ failure that required mechanical ventilation and renal replacement therapy. Virus markers were consistent with primary EBV infection. Renal function was gradually improved by corticosteroid therapy. Renal biopsy revealed acute tubulointerstitial nephritis. In situ hybridizaion EBV-encoded RNA 1 did not show the presence of virus in the kidney, but acute kidney injury may be explained by cytotoxic/suppressor T lymphocyte infiltration,

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A 65-year-old man was admitted to our hospital because of progressive dyspnea. A laboratory examination and high-resolution computed tomography (HRCT) revealed that he had interstitial pneumonia (IP) with liver dysfunction. Myeloperoxidase-ANCA (MPO-ANCA) was negative. Although his respiratory condition had become stable after initiation of steroid therapy, liver dysfunction had worsened with progressive portal hypertension. He died of hepatic insufficiency about three years after the first medical examination.
Autopsy showed that he had vasculitis of medium and small blood vessels of the spleen, lungs, and liver. The final diagnosis was classical polyarteritis nodosa (PAN). Microscopically, non-specific interstitial pneumonia was identified in the autopsied lung. The pathological findings of the liver were consistent with nodular regenerative hyperplasia (NRH). We report a case of PAN with IP and NRH preceding findings of systemic vasculitis.

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Myopericytoma is a benign tumor composed of cells that show apparent differentiation towards putative perivascular myoid cells called myopericytes. To date, only a small number of series describing myopericytomas have been reported. Here, we report a case of pulmonary myopericytoma presenting as multiple nodules in a 26-year-old man. Clinical presentation, radiological features and histopathologic findings of the patient are also discussed. The result of the histology combined with the immunohistochemical analysis led to a diagnosis of myopericytomas. To our knowledge, this is the first report of myopericytoma showing pulmonary involvement.

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A 76-year-old man suffered from swelling stoma for several weeks. A biopsy sample revealed the diffuse infiltration of large lymphoid cells which were positive for CD20, bcl-6, and MUM1. The patient was diagnosed with diffuse large B-cell lymphoma, with a non-germinal center B-cell pattern. A whole-body PET-CT scan revealed that the lymphoma was restricted to the stomal site. Bladder reconstruction was undertaken using the ileal conduit: this is the first reported case of lymphoma that developed primarily at the stoma. During the long-term maintenance after bladder reconstruction, clinicians should consider the possibility of lymphoma at the stomal site.

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We describe unusual delayed recurrent episodes of ischemic stroke in a patient with initial good recovery from pneumococcal meningitis due to progressive arterial stenosis for over 3 months. We postulate that any of the following may have been responsible for his condition: widespread cerebral vasculopathy due to the effects of purulent material bathing the base of the brain, an immune-mediated para-infectious condition, or a rebound effect of the primary inflammatory reaction that was initially suppressed by dexamethasone. This case demonstrates that progressive arterial stenosis can evolve months after bacterial meningitis and should be recognized as a potential vascular complication.

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This report describes the case of a 55-year-old woman with varicella-zoster virus (VZV) sacral meningoradiculitis (Elsberg syndrome) who presented with herpes zoster in the left S2 dermatome area, urinary retention, and constipation. Lumbar magnetic resonance imaging showed the left sacral nerve root swelling with enhancement. Thereafter, she suddenly showed massive hematochezia and hemorrhagic shock because of a rectal ulcer. To elucidate the relation between Elsberg syndrome and rectal ulcer, accumulation of similar cases is necessary. To avoid severe complications, attention must be devoted to the possibility of rectal bleeding in the early stage of Elsberg syndrome.

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Hemophagocytic lymphohistiocytosis (HLH) is a rare condition with high mortality. We report a case of a 74-year-old woman with rheumatoid arthritis who developed HLH secondary to pyelonephritis due to Escherichia coli infection following infliximab treatment. Bone marrow aspiration showed proliferation of histiocytes with hemophagocytosis. The patient died despite treatment with intravenous antibiotics intravenous methylprednisolone and intravenous immunoglobulin. Cytokine levels were measured and are discussed.

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Recent reports have shown gefitinib, epidermal growth factor tyrosine kinase inhibitor (EGFR-TKI) induced marked improvement in ECOG performance status (PS) as first-line therapy in EGFR mutation-positive patients with extremely poor PS. EGFR mutations frequently occur in east-Asian, female, non-smoking, adenocarcinoma patients, however they are occasionally detected in patients with non-adenocarcinomas or with a heavy smoking history. We describe a case in which EGFR mutation was detected in a male, current smoker, squamous cell carcinoma (SCC) patient with PS 4, who showed a marked response to the first-line gefitinib therapy. EGFR mutational analysis is recommended even for SCC patients especially in east-Asian populations.

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