Objective Patients who meet the Rome III criteria for functional dyspepsia (FD) are generally classified into the following two subgroups, those with postprandial distress syndrome (PDS) and those with epigastric pain syndrome (EPS), in order to treat the dyspeptic symptoms caused by the respective pathophysiological conditions. However, whether simple classification of FD can accurately distinguish the pathophysiological differences between PDS and EPS remains to be clarified because the pathophysiology of FD is characterized and complicated by various factors.
Methods After classifying FD patients who were not receiving medication at the initial visit, we assessed and compared the following pathophysiological factors between the PDS and EPS groups: (1) the gastric reservoir and emptying functions using a radioisotope method (n=75), (2) the autonomic nervous system (ANS) function using electrocardiography (n=45), (3) gastric mucosal atrophy and intestinal metaplasia using histological examinations (n=47), (4) endoscopic findings of the stomach, such as superficial changes, abnormal gastroesophageal flap valves (n=67) and (5) Helicobacter pylori infection (n=48).
Results The FD patients exhibited higher rates of an impaired reservoir function (49.3%), gastric emptying disorders (54.7%) and relative hyperactivity of the sympathetic nervous system (31.9%) than the control subjects. However, endoscopic and histological changes of the stomach were similar in both the FD patients and control subjects. In addition, no differences were observed in the above-mentioned factors between the PDS and EPS groups.
Conclusion The simple classification of FD patients into two subgroups according to the Rome III criteria following diagnosis does not indicate any differences in the pathophysiology related to the respective dyspeptic symptoms of FD patients.

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Objective Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. The pathogenesis of IBS is multifactorial. The aim of this study was to investigate the prevalence of IBS using the Rome III criteria in young Japanese women and to assess the effects of mental, physical, dietary and nutritional factors on IBS.
Methods In this cross-sectional study, data obtained from self-administered questionnaires, including age, height, weight, lifestyle, food habits, anxiety and depressive states and IBS-related symptoms, were analyzed in 245 participants. An established semiquantitative questionnaire available for clinical investigation (FFQg) was used to obtain a detailed assessment of food intake and the physical activity levels.
Results The prevalence of IBS was 12.0%. Of the IBS participants, constipation-predominant IBS (25.0%) was more prevalent than the diarrhea-predominant subtype (17.9%). The IBS participants had lower body mass indices, consumed less eggs and milk and were more physically active than the non-IBS participants. In addition, an anxiety state was more common in the IBS participants. Those who hesitated with evacuation of stool and who thought that there is an association between abdominal symptoms, such as constipation and diarrhea, and menstruation were more predominant among the IBS participants. The percentage of individuals who reported often rushing to the toilet within the past year and experiencing borborygmus (rumbling stomach) was greater among the IBS participants. A logistic regression analysis revealed that milk intake was an independent predictor of IBS.
Conclusion The prevalence of IBS observed in this study was similar to that reported in previous studies conducted in Japan and other countries. Mental, physical, dietary and nutritional factors have an impact on IBS.

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Objective We compared the long-term clinical and 1-year angiographic outcomes in ST-segment elevation myocardial infarction (STEMI) patients who presented between 12 to 48 hours after symptom onset and underwent emergent procedures (late reperfusion) using sirolimus-eluting stents (SES; Cypher Bx Velocity) with those of primary stenting patients who presented within 12 hours.
Methods The study design was a retrospective, nonrandomized single-center study in which the investigations were conducted in October 2012 following the enrollment of consecutive STEMI patients treated with late reperfusion (n=75) and primary stenting using SES (n=386) between September 2004 and May 2007. The incidence of the primary end points (cardiac death, nonfatal recurrent MI and definite stent thrombosis) after late reperfusion (6.7%; mean follow-up, 2,176±742 days) was not significantly different from that observed after primary stenting (8.5%; 2,237±722 days) (p=0.59). The incidence of the secondary end point (binary in-stent restenosis: % diameter stenosis greater than 50% on secondary angiography at approximately one year) after late reperfusion (11.1%, n=54) was not statistically different from that observed after primary stenting (8.0%, n=276) (p=0.45). Using a propensity score matching analysis, the incidences of the primary (6.7%, n=75) and secondary (11.3%, n=53) end points after late reperfusion were not found to be significantly different from those observed after primary stenting (8.0% and 9.4%) (p=0.75 and 0.75, respectively).
Conclusion The present small study showed the long-term clinical and 1-year angiographic outcomes after late reperfusion using SES for STEMI patients in emergent procedures in daily practice to be statistically equivalent to those observed after primary stenting using SES for STEMI patients.

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Objective The purpose of this study was to review cases of early gastric cancer associated with Endocrine cell micronests (ECM) and investigate the incidence and characteristics of these lesions.
Methods A total of 482 patients who had undergone endoscopic or surgical resection for gastric epithelial neoplasms from April 2008 to March 2010 were enrolled in this study. After detection of ECM in the lamina propria mucosa by histological examination of the resected specimens with hematoxilin-eosin staining, immunostaining was also performed. Clinical manifestation and endoscopic findings, as well as histological findings, were examined.
Results Among the 482 patients, 5 (1.0%) had ECM. The histological type of gastric epithelial cancers associated with ECM was tubular adenocarcinoma and carcinoma in situ (Tis) in the WHO classification in all 5 cases. ECM were round to oval or trabecular and located within the area of the early gastric cancer in all the 5 cases. The background gastric mucosa was Type A gastritis in 2 patients and ordinary atrophic gastritis in 2 patients. In the other case, it was difficult to determine the type of gastritis.
Conclusion ECM developed not only from the background of Type A gastritis but also from ordinary atrophic gastritis. ECM coexistent with gastric cancer were present in 1.0% of resectable gastric epithelial neoplasms.

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Objective Pulmonary tumor thrombotic microangiopathy (PTTM) is a unique, rare and fatal form of pulmonary arterial tumor embolism. The aim of this study was to evaluate the clinical characteristics and pathological and immunohistochemical findings of PTTM.
Methods Autopsy records dated between January 1983 and May 2008 in our hospital were reviewed, and those of patients who died from pulmonary tumor embolism resulting from malignant neoplasm were retrieved. The relevant tissue slides were reevaluated and examined immunohistochemically to confirm the diagnosis.
Results Among 2,215 consecutive autopsy cases of carcinoma, 30 patients (1.4%) were diagnosed with definitive PTTM. The common symptom was progressive dyspnea. A hypercoagulative state was observed in all measured cases (n = 21). The chest computed tomography findings (n = 6) included consolidation, ground-glass opacity, small nodules and a tree-in-bud appearance. Perfusion scans were performed in seven patients, six of whom demonstrated multiple small defects. The median survival time after the initiation of oxygen supplementation was nine days. The most frequent primary site was the stomach (n = 18 ; 60%) , and the most frequent histological type was adenocarcinoma (28/30 ; 93.3%) . The immunohistochemical findings for tumor cells located within the tumor emboli were positive for vascular endothelial growth factor (28/29 ; 96.6%) and tissue factor (29/29 ; 100%).
Conclusion Clinicians should suspect PTTM in cancer patients who exhibit acute worsening respiratory insufficiency accompanied by a hypercoagulative state without embolism in major pulmonary arteries. The PTTM patients evaluated in our study had very poor prognoses. Vascular endothelial growth factor and tissue factor may play important roles in PTTM.

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Objective In order to identify the factors that influence the swallowing function in patients who develop Wallenberg syndrome (WS) following lateral medullary infarction (LMI), we examined various patient characteristics, including the passage pattern abnormality (PPA) of a bolus through the upper esophageal sphincter (UES).
Methods Fifty-four pure LMI patients with dysphagia participated in this study. PPA, defined as the failure of bolus passage through the UES corresponding to the intact side of the medulla, was identified during videofluorographic swallowing evaluations of each patient. On brain magnetic resonance imaging, the subjects' lesions were classified vertically into three levels and horizontally into seven levels in relation to the involvement of the ambiguous and/or solitary nuclei. Logistic regression analyses were performed for age, sex, PPA and the vertical and horizontal sites of the lesions.
Results In terms of severity, 15 subjects were categorized as having mild dysphagia, 26 subjects were categorized as having moderate dysphagia and 13 were categorized as having severe dysphagia. Subjects with cephalic lesions, greater vertical spread of the lesion and PPA were more likely to have severe dysphagia. PPA and a greater vertical spread of the lesion were related to the severity of the functional outcome (p<0.01). The horizontal extent of the lesion was not strongly related to the prognosis.
Conclusion The presence of PPA in LMI patients is suggestive of abnormalities in the swallowing pattern and, in turn, damage to the medullary central pattern generator. The presence of PPA and a greater vertical spread of the lesion can be useful predictors of severe dysphagia.

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A perivascular epithelioid cell tumor (PEComa) is a rare type of mesenchymal tumor. Cases that arise from the liver are extremely rare. We report a case of a 41-years-old woman suffering from a hepatic PEComa with an emphasis on its imaging findings, primarily those of contrast-enhanced computer tomography (CECT) and sonography. We also conducted a literature review to evaluate imaging findings that could provide some information for preoperative diagnosis.

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A 17-year-old girl with multiple areas of skin hemangiomas that had been present since birth was referred to our institution complaining of sudden onset of dyspnea. Enhanced CT demonstrated a pulmonary thromboembolism and transthoracic echocardiogram showed a thrombus-like echo in the right ventricle. CT further revealed thrombi in the inferior vena cava (IVC) and peripheral vein. The thrombi, especially those in the RV, were highly life-threatening; therefore, immediate thrombectomy was performed and an IVC filter was placed. Because no major complications occurred, the patient was discharged 34 days after admission. In such young women, carefully using anticoagulation therapy and planning pregnancy are recommended.

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We herein present a case of cardiac sarcoidosis with atrioventricular (AV) block that was evaluated using magnetic resonance imaging (MRI) before and after pacemaker implantation. An echocardiogram showed wall thinning in the basal septum. MRI showed late gadolinium enhancement in the interventricular septum and right ventricle. Fluorine-18-fluorodeoxyglucose positron emission tomography (PET) demonstrated abnormal uptake in the same area. An MR-conditional pacemaker was implanted to treat AV block. Steroid treatment resulted in the remission of the cardiac lesions and AV block, as confirmed by PET and MRI. MR-conditional pacemakers are thus considered to have great advantages in treating cardiac sarcoidosis with AV block.

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Idiopathic left ventricular aneurysms and diverticula (LVA/Ds) are rare cardiac malformations that can be detected using certain imaging techniques. Although most patients with these malformations are clinically asymptomatic, some patients exhibit cardiac arrhythmias and other clinical manifestations. In electrophysiological studies, it is often difficult to establish the relationship between clinical manifestations of cardiac arrhythmias and those of LVA/Ds due to anatomical complexities. We herein report the case of a 67-year-old man who was successfully diagnosed with ventricular tachycardia originating from an idiopathic LVA that was clearly demonstrated on a three-dimensional electroanatomical mapping system integrated with CT imaging.

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This paper aims to describe the usefulness of transthoracic echocardiography in the follow-up of recurrent nonbacterial thrombotic endocarditis (NBTE) associated with neoplastic conditions. A 60-year-old woman with advanced uterine cancer developed recurrent areas of aseptic vegetation on the mitral valve along with cerebral, renal and splenic embolisms. Echocardiographic assessments revealed vegetation and thrombotic events on three occasions. In this case, transthoracic echocardiography was effective in following the decreased frequency of attachment of the NBTE vegetation to the mitral valve and reductions in the size of the area of vegetation following treatment with unfractionated heparin infusion, hysterectomy and chemotherapy.

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A 58-year-old woman with chronic heart failure (CHF) received cardiac resynchronization-defibrillator (CRT-D) therapy without atrial lead implantation due to longstanding atrial fibrillation (AF). Three months after oral amiodarone therapy was initiated for the treatment of non-sustained ventricular tachycardia detected by the CRT-D device, the patient's heart failure symptoms worsened and 12-lead electrocardiography showed newly emerged p-waves with atrioventricular (AV) dissociation. Immediately after the device was upgraded to the DDD-biventricular pacemaker, the patient's heart failure symptoms and cardiac function dramatically improved, which suggests that AV dissociation has a much more negative impact on the cardiac function than AF in patients with CHF.

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22q11.2 Deletion syndrome is recognized to be a major cause of congenital hypoparathyroidism, and affected patients exhibit a range of autoimmune characteristics. The syndrome becomes apparent in early childhood and is rarely diagnosed in adulthood. This report describes an adult case of 22q11.2 deletion syndrome first diagnosed in a 36-year-old woman with hypocalcemia caused by hypoparathyroidism and Hashimoto's thyroiditis. It is important to diagnose 22q11.2 deletion syndrome in adults because such patients are still at high risk for developing treatable diseases, such as hypocalcemia and autoimmune diseases.

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A woman over 70 years of age presented with anemia and appetite loss. She had no history of blood transfusions, although she had been receiving iron infusions for anemia for seven years. She had an elevated serum ferritin level (7,951 ng/mL) one month before admission. Abdominal computed tomography showed increased hepatic density and echocardiography showed normal heart valves and heart-wall motion. The patient eventually experienced atrial tachycardia and atrial fibrillation and died of heart failure. An autopsy revealed iron deposits in the liver, pancreas, adrenal glands, thyroid gland, gastric mucosa and myocardium. Iron-overload cardiomyopathy was diagnosed based on the iron deposits, myocardial disarray and interstitial fibrosis.

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A 42-year-old woman with a history of idiopathic portal hypertension (IPH) developed type 1A diabetes and was found to have chronic thyroiditis. The concurrence of IPH and type 1A diabetes has been previously reported in only one case. This is the second known case, and our patient was classified as having autoimmune polyglandular syndrome (APS) III. The patient's HLA DR and DQ alleles were determined to be susceptible to autoimmune thyroid diseases but resistant to type 1A diabetes.

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Short bowel syndrome (SBS) is characterized by a malabsorptive state. It is conceivable that the coexistence of SBS and end-stage renal disease can lead to severe metabolic acidosis; however, such a condition has rarely been documented. We herein describe the case of a 64-year-old man with SBS who required maintenance hemodialysis. Persistent metabolic acidosis and mineral and bone disorders should be of particular concern in hemodialyzed patients with SBS.

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We herein report the case of a 75-year-old man who developed an increased serum creatinine level (4.93 mg/dL) and oliguria with massive proteinuria (7.14 g/day) on the second day after a single oral administration of high-dose (56 mg) minodronate. The histology of a renal biopsy showed one area of glomerular sclerosis among 20 glomeruli with global foot process effacement of podocytes and mild infiltration of lymphocytes and eosinophils into the interstitial space. Acute kidney injury in nephrotic syndrome due to focal segmental glomerular sclerosis induced by minodronate was diagnosed. Following cessation of minodronate without the administration of immunosuppressive agents, the patient's renal function and proteinuria markedly improved.

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A 26-year-old woman was admitted due to an altered mental status and generalized tonic-clonic seizures. She had experienced chronic migraine-like headaches, progressive bilateral hearing loss, a short stature and nephrotic syndrome. Laboratory data showed elevated lactate and pyruvate levels. Brain MRI using diffusion-weighted imaging revealed a hyperintense lesion in the left temporal lobe. MR angiography revealed segmental stenosis at the C1 and M1-2 junction. A genetic study revealed a mitochondrial DNA A3243G point mutation. The patient's clinical symptoms and MRI/MR angiography (MRA) findings improved within four weeks. We herein discuss the possible pathophysiology involving both stroke-like episodes and reversible vasoconstriction.

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Eosinophilic meningitis is defined as the presence of 10 eosinophils/mm³ in the cerebrospinal fluid (CSF) or eosinophils accounting for more than 10% of CSF leukocytes. A 76-year-old man who developed cognitive dysfunction and consciousness disturbance had eosinophilic meningitis (his CSF contained 19.0% eosinophils). Because the etiology was unknown, we performed a brain biopsy. The pathological findings showed inflammatory infiltration in the small-sized arteries of the meninges. The patient was ultimately diagnosed as having primary angiitis of the central nervous system (PACNS). Eosinophilic meningitis occurring in a patient with PACNS is extremely rare, and this is the first report of this condition in Japan.

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An 83-year-old man presented with a three-week history of dyspnea. The clinical features suggested a diagnosis of relapsing polychondritis (RP); however, the patient died of heart failure. An autopsy revealed active chondritis of the tracheal and bronchial cartilage. Furthermore, giant cell myocarditis (GCM) and myositis were detected. To the best of our knowledge, this represents the first report of RP complicated by GCM and myositis. In patients with RP, GCM and myositis, CD163-positive macrophages and T-cells are most common, and the T-cell subset exhibits CD8 predominance. Common mechanisms of tissue damage caused by cytotoxic T-cells are likely to contribute to RP, GCM and myositis.

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DRESS (drug rash with eosinophilia and systemic symptoms) syndrome is a severe reaction triggered by drugs that manifests as pyrexia and eosinophilia with involvement of the skin and internal organs. We herein describe the case of a patient who developed hyperuricemia after receiving treatment for tuberculosis, then took allpurinol and developed DRESS syndrome with a contextual coma and right hemisyndrome. This report describes for the first time the presence of vasculitic cerebral involvement in a patient with DRESS syndrome. The cerebral vasculitis responded to treatment, showing clinical and instrumental remission. In cases such as this, allergic cerebral vasculitis should be considered in the differential diagnosis because it can be treated if recognized early, thus leading to remission without the development of any sequelae.

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A 77-year-old man had undergone left-lobe liver resection and a choledochojejunostomy six years previously, and thereafter he suffered from a postoperative relapse of cholangitis. He was admitted to our hospital due to liver abscesses and bacteremia caused by multidrug-resistant Pseudomonas aeruginosa. Empirical treatment with piperacillin/tazobactam was started, and the patient initially recovered. However, he developed a second case of sepsis caused by piperacillin/tazobactam-resistant P. aeruginosa bacteremia originating from a new liver abscess. We changed the piperacillin/tazobactam to colistin and flomoxef and continued the two antibiotics for one month. During the antibiotic therapy, the patient successfully underwent bile duct stent placement.

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Pneumococcal pericarditis complicated by a malignant effusion has not been reported previously. We experienced an independent 62-year-old man with lung cancer who was hospitalized for acute onset of atrial flutter and moderate pericardial effusion. He was afebrile; however, pericardiocentesis showed Streptococcus pneumoniae and malignant squamous cells in purulent pericardial fluid. This case shows that clinicians should keep in mind the possibility of afebrile bacterial pericarditis in cancer patients with pericardial effusions and that cultures of pericardial fluid should be performed in such patients along with cytological examinations.

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A 57-year-old woman presented with a fever and left-sided hip and back pain. The hip pain was explained by L3 radiculopathy because the pain was distributed on the L3 dermatome accompanied by allodynia. On the other hand, the back pain was located on the left side 1 cm from the spinal process of the L3-4 vertebrae. Enhanced computed tomography of the abdomen revealed an abscess in the left paravertebral muscle, and pyomyositis was diagnosed. Following percutaneous drainage via ultrasound, both the hip and back pain immediately improved. Paraspinal pyomyositis as well as lesions inside the spinal canal should therefore be considered in the differential diagnosis of patients presenting with fever, back pain, and radiculopathy.

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