Objective Genotype 1 chronic hepatitis C (G1CHC) is generally accompanied by metabolic disturbances related to visceral obesity, such as insulin resistance, steatosis, or dyslipidemia. Because these abnormalities negatively influence the clinical course of G1CHC, we sought to clarify the effect of visceral obesity on the pathophysiology of G1CHC. Methods We evaluated 180G1CHC patients for the presence of visceral obesity on the basis of computed tomography findings. Multivariate analysis was performed to estimate the relationship between visceral obesity and demographic, viral, and biochemical characteristics of patients. The associations of visceral obesity with histological findings and serum adipokine levels were also analyzed. Results Multiple logistic regression analysis revealed that visceral obesity was independently associated with metabolic syndrome, platelet count, high-density lipoprotein level, and serum viral load in elderly patients (≥65 years). Multiple linear regression analysis confirmed the association between visceral obesity and high viral load. However, visceral obesity was not correlated with viral load in non-elderly patients (<65 years). Histological data (160 patients) demonstrated the significant association between visceral obesity and steatosis. Furthermore, patients with visceral obesity showed increase in the severity of fibrosis with advancing age. However, age-associated fibrosis progression was not evident in patients without visceral obesity. The serum adiponectin level was significantly low in patients with visceral obesity, whereas those of leptin, tumor necrosis factor-α, and interleukin-6 were not affected significantly. Conclusion Visceral obesity was associated with high viral load and histological damage in elderly patients with reduced adiponectin levels.
Objective This study was designed to identify why the central blood pressure (cSBP) values obtained using the catheter method tend to be higher than brachial systolic blood pressure (bSBP) values obtained using the cuff method. Methods This study enrolled 20 patients who underwent coronary angiography (CAG) (mean age, 68.9 years; 13 men). Using the catheter method, a pressure guide wire was inserted via the radial artery at the time of CAG to measure the cSBP. The guide wire was then removed and the bSBP was obtained using two methods (the pressure guide wire method and the cuff method). The cSBP obtained with the catheter and the bSBP obtained with the cuff were compared, as were the bSBP obtained with the cuff and the bSBP obtained with the catheter. Results The cSBP obtained with the catheter was 4.6 mmHg higher than the bSBP obtained with the cuff. The bSBP obtained with the cuff was 8.3 mmHg lower than the bSBP obtained with the catheter. The cSBP obtained with the catheter was 1.7 mmHg lower than the bSBP obtained with the catheter. Conclusion In elderly patients with evident or suspected coronary heart disease, the finding of a higher cSBP measured using the catheter method than the bSBP obtained using the cuff method is attributable to bSBP underestimation (by 8.3 mmHg) using the cuff method compared to the bSBP directly obtained using the catheter method.
Objective The Japan Atherosclerosis Society (JAS) has recommended serum lipid management goals (SLMGs) based on the coronary heart disease (CHD) risk classification included in its 2007 guidelines for the diagnosis and prevention of atherosclerotic cardiovascular disease in the Japanese population (JAS GL 2007). The Japan Society of Ningen Dock created a database of subjects receiving annual health examinations. Using this database, we evaluated the lifestyles of patients with dyslipidemia by identifying risk factors for CHD development based on the JAS recommendations. Methods A total of 223,407 adults (men: 138,435; women: 84,972) aged between 20 and 79 years were enrolled in the analysis. Those who were already being treated for dyslipidemia and had a history of CHD were excluded. CHD risk factors in the JAS GL 2007, such as an advanced age, hypertension, diabetes mellitus, smoking habits, a family history of coronary artery disease, and low high-density lipoprotein cholesterol levels, were used for the evaluation. The subjects were categorized into three groups (Categories I, II and III) according to the number of risk factors other than the low-density lipoprotein cholesterol (LDL-C) level. We evaluated the percentage of goals met during primary prevention in each group. The serum LDL-C levels were calculated using the Friedewald formula. The LDL-C levels were measured using a direct homogeneous assay if the triglyceride level was ≥400 mg/dL. Results Overall, 72.9% of the subjects achieved their SLMGs. Most subjects (>90%) with no CHD risk factors other than the LDL-C level in Category I achieved their SLMGs, while less than half of the subjects in Category III achieved their goal. Conclusion Smoking cessation and medication administration should be considered in patients in Categories II and III.
Objective We previously reported that, on brain MRI, iNPH features were observed in approximately 1% of asymptomatic elderly community dwellers. This phenomenon is designated asymptomatic ventriculomegaly with features of iNPH on MRI (AVIM). The aim of the present study was to clarify whether a subclinical decline in the neuropsychological function is present in patients with AVIM. Methods We examined eight subjects with AVIM, six subjects with possible iNPH and 21 elderly controls. Neuropsychological tests were used, including the mini-mental state examination (MMSE), the Hasegawa dementia scale-revised (HDS-R), the frontal assessment battery (FAB), the trail making test A&B and semantic and letter verbal fluency tests. Results When comparing the individuals with AVIM with the control subjects, significant differences were found in the scores achieved on the semantic verbal fluency tests and Luria's motor series (fist-edge-palm), a subtest of the FAB. Conclusion The present study suggests that individuals with AVIM demonstrate a slight subclinical decline in the cognitive function and motor regulation, which may represent a prodromal stage of iNPH.
Objective To assess longitudinal changes in the clinical features of patients with amyotrophic lateral sclerosis (ALS), we performed a retrospective hospital-based study covering 35 years. Methods We investigated 287 patients (154 men and 133 women) with sporadic ALS hospitalized at the Department of Neurology at Gunma University Hospital (Japan) between 1978 and 2012. All patients fulfilled the diagnostic criteria for definitive, probable or laboratory-supported probable ALS according to the revised El Escorial criteria. Results Two hundred patients (69.7%) exhibited limb onset and 87 patients (30.3%) exhibited bulbar onset of the disease. The percentage of patients who showed bulbar onset of the disease increased steadily over the 35 years from 14.2% (1978-82) to 38.3% (2008-12) (p<0.01, r=0.470). The mean age at onset was 62.1 ± 11.7 years, and the age at onset increased significantly over time from 51.7 years (1978-82) to 64.9 years (2008-12) (p<0.001, r=0.294). In addition, the percentage of patients whose age at onset was 70 years or more increased from 0% (1978-82) to 38.2% (2008-12). The percentage of ALS patients with dementia increased from 0% (1978-82) to 20.2% (2008-12). Conclusion Our findings demonstrate that, among patients with sporadic ALS, the age at disease onset, the proportion of patients with disease onset at 70 years of age or higher, the proportion of patients with dementia and the proportion of patients with bulbar onset ALS have increased significantly over the past 35 years. The longitudinal changes observed in the clinical features of ALS may reflect the increasing age at disease onset.
A 60-year-old woman was admitted for the treatment of a gastric neuroendocrine tumor (NET) associated with type A chronic atrophic gastritis. The lesion measured 10 mm in diameter, and a computed tomography scan did not reveal any metastatic lesions. Endoscopic submucosal dissection (ESD) was subsequently performed. A histological examination revealed three gastric NETs, two of which exhibited vessel invasion. Endocrine cell micronests associated with a high risk of recurrence were also observed. Therefore, the patient underwent total gastrectomy with lymph node dissection. Because vessel invasion can occur in patients with small gastric NET G1, the use of ESD should be considered to carefully estimate the presence of invasion.
A woman in her 50s was found to have a pancreatic mass on abdominal ultrasound. The tumor measured 40 mm in diameter and included a cystic lesion and calcification. In this case, we suspected a diagnosis of solid pseudopapillary neoplasm (SPN) due to the findings observed on various images. However, we were unable to exclude the possibility that the lesion was a neuroendocrine tumor. Therefore, we performed endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA). In addition, in order to confirm the diagnosis of SPN, we performed minimized resection (segmental pancreatectomy). Obtaining a definitive preoperative diagnosis of SPN using EUS-FNA can guide the surgical approach.
A 75-year-old Japanese woman with acute mitral valve prolapse and regurgitation, that developed one month previously, suffered from intractably progressive congestive heart failure (CHF). However, the emergent surgery was declined, and pharmacological treatment was discontinued due to hypotension and malignant arrhythmia. She was treated with 5-8 cmH2O of continuous positive airway pressure (CPAP) to manage CHF and Cheyne-Stokes respiration during the preoperative period of five weeks, after which plastic surgery of the mitral valve was successfully performed. CPAP can be an effective non-pharmacological treatment for CHF, unloading the left ventricle hydrostatically in order to reduce mitral regurgitation and improve oxygenation.
A 67-year-old Japanese man with recurrent nephrotic syndrome and impaired kidney function had a sporadic, elderly-onset case of glomerulopathy with fibronectin deposits. The daily urinary protein, serum albumin, blood urea nitrogen, and creatinine levels were 3.6 g/day, 2.7 g/dL, 19.5 mg/dL, and 1.70 mg/dL, respectively. Kidney biopsy samples were evaluated using electron microscopy and demonstrated membranoproliferative glomerulonephritis-like lesions with massive subendothelial depositions and no fibrillary structures. Immunofluorescent studies showed 1+ staining for IgA, C1q, and fibrinogen. Anti-fibronectin immunostaining demonstrated that the subendothelial deposits were positive for fibronectin. The administration of prednisolone and mizoribine improved the nephrotic syndrome.
A 68-year-old woman without asthma presented with a cough and abnormal shadows on a chest X-ray. Computed tomography showed right middle lobe atelectasis and centrilobular nodules with a tree-in-bud appearance in the other lobes. The patient's sputum repeatedly yielded positive cultures of nontuberculous mycobacteria (NTM); however, no fungi were detected. A transbronchial biopsy showed allergic mucin with eosinophils, although the findings were not diagnostic. We suspected that the patient had pulmonary mycobacteriosis; however, treatment for this condition failed. We then performed thoracoscopy for further evaluation and treatment of the NTM infection. The resected specimen obtained from the right middle lobe exhibited the characteristic findings of allergic bronchopulmonary mycosis without evidence of mycobacterial infection. The administration of corticosteroids and itraconazole resulted in improvement of the patient's condition. The NTM appeared to be simply a coincidental colonization of the resected middle lobe bronchus. The absence of asthma, the inability to isolate fungi and the repeated isolation of NTM made it difficult to differentiate allergic bronchopulmonary aspergillosis from NTM infection.
Disseminated visceral varicella-zoster virus (VZV) infection rarely occurs in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT). To date, only a few cases of isolated VZV-induced fulminant hepatitis following allo-HSCT have been reported. We herein describe the case of a 47-year-old Japanese man with multiple myeloma who developed fulminant hepatitis 17 months after undergoing allo-HSCT. Despite receiving fresh frozen plasma and platelet transfusions, he developed a bleeding tendency (systemic purpura, petechiae and oral bleeding), slipped into a coma and eventually died. He was retrospectively diagnosed with viscerally disseminated VZV infection based on a postmortem examination and multiplex polymerase chain reaction (PCR) amplification.
Multiple system atrophy with predominant parkinsonism (MSA-P) usually shows poor responsiveness to dopaminergic medications. We herein describe a patient with MSA-P who exhibited a good response to pramipexole but not to an ordinary dose of L-dopa. Positron emission tomography (PET) displayed severely impaired presynaptic dopaminergic availability and relatively preserved postsynaptic D2 receptor binding capacity. The pharmacokinetic analyses demonstrated relatively low bioavailability for L-dopa and adequate plasma levels of pramipexole, even at baseline, on a stable daily dose. The PET features and pharmacokinetic differences between L-dopa and pramipexole indicate the presence of unique therapeutic responses to dopaminergic medications in the patient.
We herein report the case of a patient with pancreatic cancer who manifested features of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and autoimmune hemolytic anemia (AIHA). A 78-year-old Japanese man presented with AIHA and was treated with steroids and splenectomy. Although the AIHA improved following splenectomy, the patient suffered from sensorimotor neuropathy soon after undergoing surgery. The electrophysiological features indicated demyelinating neuropathy. The neuropathy was refractory to immunomodulatory treatment, and intensive investigations revealed pancreatic cancer. The patient's neurological deficits improved significantly after the surgery for cancer. Although the combination of AIHA and CIDP has been reported anecdotally, this is the first case of the coexistence of these diseases as paraneoplastic syndromes.
We herein report a case of methemoglobinemia induced by trimethoprim-sulfamethoxazole (TMP/SMX). A 41-year-old woman with systemic lupus erythematosus (SLE) received TMP/SMX for prophylaxis of pneumocystis pneumonia (PCP) on the 7th day of hospitalization. She suddenly developed dyspnea and cyanosis on the 9th day of hospitalization. The level of oxygen saturation (SaO2) decreased, and the concentration of methemoglobin (MetHb) in the blood was elevated. We diagnosed the patient with methemoglobinemia induced by TMP/SMX. Methemoglobinemia should be considered in cases of sudden dyspnea following TMP/SMX administration.