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 at 21 institutes nationwide. Using this database, we evaluated the efficacy of current treatment for patients with dyslipidemia by identifying risk factors for CHD development, based on the JAS recommendations.
Methods This multicenter, retrospective study was conducted using data obtained from 21 institutions across Japan. 17,991 adults taking dyslipidemia medications were enrolled. The JAS GL 2007 was used for evaluation. Since the guideline indicated separate goals (secondary prevention for subjects with a prior history of CHD and primary prevention for those with other CHD risk factors), we evaluated the percentages of goals met. The serum low-density lipoprotein cholesterol (LDL-C) levels were calculated using the Friedewald formula. The LDL-C level was measured using a direct homogeneous assay if the triglycerides (TG) level was 400 mg/dL or higher.
Results The achievement rates of the SLMGs were as follows: LDL-C, 72.3%; high-density lipoprotein cholesterol (HDL-C), 94.6%; and TG, 69.7%.
Conclusion Our results regarding Japanese patients receiving dyslipidemia treatment for CHD prevention identified insufficient reductions in the levels of LDL-C and TG in those at high risk for CHD and suggest the need for more aggressive lipid-lowering therapy.

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Objective Some angiotensin receptor blockers (ARBs), including irbesartan, increase the peroxisome proliferator-activated receptor (PPAR)-g activity in vitro. The aim of this study was to evaluate the interactions between obesity and the effects of irbesartan on inflammatory cytokines in chronic glomerulonephritis patients without diabetes.
Methods The anti-inflammatory effects of irbesartan were evaluated in 29 hypertensive chronic glomerulonephritis patients without diabetes in a prospective, single-arm study.
Results Following treatment with irbesartan for 26 weeks, blood pressure and proteinuria significantly decreased, as previously reported (blood pressure decreased from 142±1/87±1 to 131±1/81±1 mmHg and the urine protein/creatinine ratio decreased from 1,030±143 to 779±121 mg/g Cr). BMI did not significantly change after the study. Among the inflammatory parameters, the concentrations of adiponectin and high-sensitivity C-reactive protein (hsCRP) significantly improved after treatment; however, the changes in the concentrations of interleukin-6 (IL-6), tumor necrosis factor (TNF)-a and leptin did not reach statistical significance. Moreover, the changes in these five parameters following treatment were moderately correlated with the BMI values obtained at the initiation of the study, and the improvements were particularly prominent in those with a BMI greater than 25. Improvements in proteinuria were significantly correlated with increases in the adiponectin concentration, but not with BMI. There was also a moderate correlation between the changes in the adiponectin and insulin concentrations.
Conclusion Irbesartan improves metabolic parameters in nondiabetic hypertensive chronic glomerulonephritis patients, especially those with a high BMI. Improving the adiponectin concentration may be important for reducing proteinuria.

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Objective The main purpose of this study was to translate the Calgary Sleep Apnea Quality of Life Index (SAQLI) and to evaluate the reliability, validity and responsiveness of the Japanese version of the SAQLI (SAQLI-J).
Methods Translation of the SAQLI questionnaire into the SAQLI-J questionnaire was performed following the guidelines of cross-cultural adaptation of health-related quality of life (QOL) measures. All patients completed the following questionnaires both at baseline and three months later: the SAQLI-J, the Medical Outcome Survey Short Form (SF-36) and the Epworth Sleepiness Scale (ESS). The SAQLI-J was conducted by an interviewer.
Patients One hundred and fifteen obstructive sleep apnea hypopnea syndrome (OSAHS) patients were recruited into the present study.
Results The internal consistency and test-retest reliability of the total SAQLI-J scores (SAQLI-J total) were both excellent. Regarding construct validity, the SAQLI-J was tested by measuring the inter-domain correlation between the SAQLI-J domains and the SF-36 domains. All of the SAQLI-J domains and the SAQLI-J total were found to be moderately to highly correlated with the domains of the SF-36. Moreover, the responsiveness of the SAQLI-J total measured according to the standardized response mean was found to be moderate, and the SAQLI-J was found to be more responsive than the SF-36 for detecting changes in the QOL after continuous positive airway pressure treatment.
Conclusion The results suggest that the SAQLI-J is a valid, reliable and responsive health-related QOL questionnaire for use in Japanese OSAHS patients.

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Objective Community-acquired pneumonia (CAP) remains a major cause of death. No studies have reported the use of rapid influenza diagnostic tests (RIDT) for the etiological diagnosis, and the factors contributing to severity and mortality have not yet been fully investigated. The aim of this study was to review the etiologies of CAP using RIDT and to identify risk factors related to the severity and mortality of the disease.
Methods This retrospective study assessed these factors in hospitalized patients, with special emphasis on microbial etiology.
Results A total of 1,032 patients aged 63.9±18.3 years were studied, 66.2% of whom were men. Microbial identification was obtained in 57.0% of the cases. The most frequent causative microbial agents were Streptococcus pneumoniae, Mycoplasma pneumoniae and the influenza virus, and the second most frequent pathogens in the patients with severe CAP and the non-survivors were S. pneumoniae and the influenza virus. Age (≥65 years), chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, dementia and Legionella spp. infection and polymicrobial infection were each found to be independent factors related to severity in the multivariate analysis, whereas "unidentified pathogen" was found to be an independent factor for non-severe CAP. Age (≥65 years), chronic pulmonary aspergillosis, post-lung cancer surgery and severe CAP were found to be independent factors for non-survival according to a multivariate analysis.
Conclusion In addition to S. pneumoniae, the influenza virus was a frequent cause of CAP overall and a frequent causative pathogen in both severe cases of CAP and non-survivors. Legionella spp. infection and polymicrobial infection were found to be an independent factor for the severity of CAP along with advanced age and certain comorbidities. An advanced age, certain respiratory comorbidities and severe CAP were found to be important independent factors for the mortality of CAP.

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Objective The long-term use of levodopa to treat Parkinson's disease (PD) is often limited by the development of motor complications (e.g. levodopa-induced dyskinesia, LID). We hypothesized that a non-ergot dopamine agonist with strong affinity for D₃ dopamine receptors (pramipexole) may improve LID in patients taking an ergot D₁/D₂ dopamine agonist.
Methods Patients with PD and LID being treated with levodopa in addition to an ergot dopamine agonist were randomized to either a group in which pramipexole was added to current medications or a group in which the ergot dopamine agonist was switched to pramipexole. Dyskinesia was evaluated using Core Assessment Program for Surgical Interventional Therapies scores. The Unified Parkinson's Disease Rating Scale scores, Modified Hoehn and Yahr stages (at 'on' time), Parkinson's Disease Questionnaire-39 scores and Clinical Global Impression-Improvement scores were also used for evaluation.
Results At 24 weeks, pramipexole alleviated LID with more efficiency in the switch group.
Conclusion Pramipexole may be a therapeutic option for treating LID because its effects on D₃ dopamine receptors may balance the D₁ dopamine receptor supersensitivity associated with LID.

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Objective The incidence of sporadic inclusion body myositis (sIBM) in the Japanese population has increased, and some researchers have suggested that race and genetic background may influence the clinical features of the disease. The aim of this study was to clarify the demographic features of Japanese patients with sIBM.
Methods We retrospectively evaluated the demographic features of consecutive patients who were referred to our institution between 1995 and 2011 for diagnostic muscle biopsies and who subsequently were diagnosed to have sIBM.
Results Seventy-three patients comprising 54 men and 19 women received a diagnosis of sIBM during the study period. The patients were divided into two groups based on the date of diagnosis (before and including 2002, and after 2002). The annual number of patients who received a diagnosis of sIBM increased significantly from 3.6±1.6 (mean ± SD) before and including 2002 to 4.9±3.1 (mean ± SD) after 2002 (p<0.05), whereas the annual number of patients who received a diagnosis of polymyositis (PM) or dermatomyositis (DM) remained consistent from 1995 to 2011. The ratio of PM and DM to sIBM was 7.6 during the period from 1995 to 2002 and 5.5 during the period from 2003 to 2011. However, the age-adjusted annual number of patients newly diagnosed with sIBM did not increase significantly after 2002.
Conclusion The number of Japanese patients with sIBM appears to have increased in recent years; however, the characteristics of the patients have not changed. Considering the increased size of the elderly population, prolonged lifespans could explain the demographic movement of sIBM in Japan.

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Objective The aim of the present study was to evaluate the plasma vitamin D (vit D) levels and their association with the disease activity in patients with ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (uSpA) compared with healthy populations.
Methods This study included 161 spondyloarthritis patients (113 uSpA patients and 48 AS patients) attending our rheumatology out-patient clinic, along with 92 controls.
Results The plasma vit D levels were 18 μg/L (8-38) in the AS group, 20 μg/L (4-92.3) in the uSpA group and 24.3 μg/L (7.2-76.8) in the control group. The plasma vit D levels of the AS patients were significantly lower than those of the patients in the control group (p=0.004). The men in the AS group had significanly lower vit D levels than those in the control group (p=0.005). On the other hand, the women in the uSpA group had significanly lower vit D levels than those in the control group (p=0.011). The vit D levels were inversely related to both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the AS patients (p=0.002, R=-0.428; p<0.001, R=-0.592, respectively). This correlation was not demonstrated in the uSpA patients. The vit D levels were not found to correlate with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) levels in either the AS or uSpA patients.
Conclusion 25-hydroxy-vit D deficiency is frequently observed in patients with SpAs. In this study, vit D deficiency was much more prominent in the male AS patients. On the other hand, among women, the uSpA patients exhibited much more prominent vit D deficiency than the control group subjects. The acute phase response may inversely affect the vit D levels in AS patients.

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Objective Previous studies have shown a possible role for obstructive sleep apnea syndrome (OSAS) in the development and/or progression of chronic kidney disease (CKD). However, the impact of treatment for OSAS on CKD has not been clarified. The aim of this study was to investigate the influence of OSAS and the short-term effects of nasal continuous positive airway pressure (CPAP) on the estimated glomerular filtration rate (eGFR).
Methods We evaluated 38 men with OSAS diagnosed on polysomnography. The associations between the eGFR and patient characteristics, including polysomnographic parameters, were evaluated. A multivariate linear regression analysis was performed to determine the independent variables associated with eGFR. We reassessed the polysomnographic data and eGFR values after three months of CPAP treatment.
Results The mean serum creatinine level was 0.83±0.10 mg/dL and the mean eGFR was 77.3±12.0 mL/min/1.73 m². A univariate analysis revealed that an older age (p<0.001), a longer mean apnea duration (p=0.006) and BMI (p=0.022) were significantly associated with lower eGFRs. A multivariate linear regression analysis showed that the independent factors associated with lower eGFRs were older age (p<0.001) and a longer mean apnea duration (p=0.048). Three months after CPAP treatment, there were significant decreases in the serum creatinine levels (p=0.013) and increases in eGFR (p=0.014).
Conclusion OSAS, especially that associated with an older age and a longer mean apnea duration, may contribute to lowering eGFR values, which can be reversed by CPAP treatment.

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A 58-year-old woman with severe constipation and a habit of straining at defecation was diagnosed to have mucosal prolapse syndrome. One year later, her primary symptom changed to bloody diarrhea. The colonoscopic and histological findings were consistent with the characteristics of cap polyposis. After nine years, her symptoms and colonoscopic abnormalities disappeared completely without treatment. For two years since that time, the patient has remained well with normal endoscopy findings and a high value of anti-Helicobacter pylori immunoglobulin G. In this case, cap polyposis might have developed via mucosal prolapse syndrome and then regressed completely, irrespective of the Helicobacter pylori infection.

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A 74-year-old man was transferred to our hospital due to melena and syncope. He had a history of an abdominal aortic aneurysm treated with aortobifemoral grafting 15 years previously. One month before admission, he reported several episodes of melena for which he underwent repeated gastrointestinal endoscopic examinations. None of these examinations revealed the site of gastrointestinal bleeding. Aortoenteric fistulae can therefore be missed if they are not considered in the differential diagnosis of gastrointestinal bleeding due to their rarity. As a result, secondary aortoenteric fistulae should therefore be considered in any patient presenting with gastrointestinal bleeding and a history of aortic surgery.

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Arterio enteric fistulas (AEFs) are rare. We herein report a case of a primary arterio enteric fistula of the rectum associated with Takayasu arteritis. A 77-year-old woman presented with acute massive hematochezia and was taken to our hospital. Colonoscopy revealed pulsatile extrinsic rectal wall compression with an exposed blood vessel. Transvaginal ultrasonography and Doppler ultrasound revealed a localized vascular growth laying on the dorsal surface of the uterus that showed an arterial blood-flow signal. We diagnosed the patient to have a pelvic aneurism that had formed a fistula within the rectal wall. We eliminated the aneurysm by ligating the drainage and feeder arteries. Following surgery, the patient did not experience any relapses of hematochezia.

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A 42-year-old woman with hepatitis C virus-related cirrhosis underwent peginterferon alpha-2b therapy combined with ribavirin but could not achieve a sustained viral response. Following discontinuation of this combined therapy, the patient's serum transaminase levels suddenly became elevated. Therefore, the administration of very-low-dose peginterferon alpha-2a with ursodeoxycholic acid was introduced. Thereafter, the patient's serum transaminase levels gradually improved. Four years later, enhanced computed tomography showed shrinkage of the spleen and enlargement of the liver. Long-term combined therapy with very-low-dose peginterferon and ursodeoxycholic acid may be effective not only in preventing disease progression, but also in improving portal hypertension in patients hepatitis C virus-related cirrhosis.

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A 70-year-old woman with no history of diabetes was admitted to the hospital for the management of hypoglycemia. Her fasting plasma glucose level was 54 mg/dL with an extremely high serum immunoreactive insulin level (1,210 μU/mL). She had high titers of anti-insulin antibodies and exhibited the DRB1*0406 genotype for HLA-DR4, leading to a diagnosis of insulin autoimmune syndrome. She had been taking several health preparations for approximately 10 years; however, all were thiol group-free. Due to frequent episodes of nocturnal hypoglycemia, the health preparations were discontinued and the patient was treated with cornstarch. This protocol successfully ameliorated the hypoglycemic episodes and normalized the patient's laboratory and serological test results.

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Fibroepithelial polyps of the bronchus are uncommon. We herein report a rare case of a recurrent bronchial fibroepithelial polyp. A 61-year-old man was admitted to the hospital due to recurrent pneumonia. Chest computed tomography showed consolidation and atelectasis in the right lower lobe. Bronchoscopy revealed a mobile polypoid tumor protruding from the right lower lobe bronchus. We performed endobronchial resection, and a pathological examination revealed a fibroepithelial polyp. However, surveillance bronchoscopy performed six months after tumor resection detected a relapse. We herein report a case of a recurrent bronchial fibroepithelial polyp and also review the relevant literature.

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We herein report the rare case of a 56-year-old man who suffered from heat stroke. Although he was in a coma with convulsions on arrival and developed multiorgan failure, he recovered after two weeks of successful treatments. Hyperintense signals on the right temporoparietooccipital cortex, which disappeared within one week, were demonstrated on diffusion-weighted magnetic resonance images. A diagnosis of transient cortical injury caused by heat stroke was suggested. Although the cerebellum is most susceptible to lesion formation, the mechanisms underlying heat stroke are multifactorial and may result in a variety of brain lesions.

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We herein report unusual basal ganglia hyperintense lesions on noncontrast T1-weighted magnetic resonance imaging in a patient with central nervous system metastasis from lung adenocarcinoma that was treated with gefitinib. T2*-weighted magnetic resonance imaging showed no hypointense lesions, thereby excluding the possibility of calcification or haemorrhage. A stereotactic brain biopsy of the left basal ganglia lesions revealed atypical cells, some of which formed a glandular lumen with a micropapillary pattern. These cells were immunopositive for markers of lung adenocarcinoma, thereby confirming the diagnosis of metastasis. We speculate that proteins, including carcinoembryonic antigens from the adenocarcinoma cells in the basal ganglia, may have contributed to the hyperintensity observed on noncontrast T1-weighted magnetic resonance imaging.

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A 60-year-old woman with a two-year history of rheumatoid arthritis (RA) developed recurrent two- to three-day attacks of fever (>38°C) accompanied by monoarthritis of the right hip joint. The first attack occurred two months after beginning anti-tumor necrosis factor-α therapy. Since a diagnosis of infectious arthritis was suspected, the therapy was discontinued. Thereafter, the patient repeated similar episodes; however, oral colchicine effectively controlled the attacks. The patient was diagnosed to have familial Mediterranean fever (FMF). The clinical manifestations of FMF mimic infectious complications during anti-RA therapy. Clinicians should therefore consider the possibility of FMF development in RA patients exhibiting recurrent febrile attacks.

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Acute bacterial pericarditis is a rare but devastating complication of Staphylococcus aureus bacteremia (SAB). We herein describe the case of a previously healthy 81-year-old woman with SAB complicated by pericarditis that evolved into cardiac tamponade despite the administration of optimal antimicrobial therapy for 11 days. Three adhesion factor genes, fnbA, clfA and clfB, were identified in the causative isolate.

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We herein report the case of an HIV-positive man who was diagnosed with idiopathic esophageal and oropharyngeal ulceration. The esophageal and oropharyngeal ulcers were considered to be idiopathic and related to HIV infection after excluding the possibility of infection with known pathogens. Both the esophageal and oropharyngeal ulcers showed significant improvements following antiretroviral therapy alone. Idiopathic esophageal ulcers are a well-known complication of late-stage HIV infection. However, involvement of both the esophagus and pharynx is rare. Furthermore, antiretroviral therapy without concomitant steroids is effective against idiopathic esophageal and oropharyngeal ulcers related to HIV infection.

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An 88-year-old man died of streptococcal toxic shock syndrome due to a group G streptococcus infection that was possibly caused by an intramuscular injection given 30 hours earlier in his right deltoid muscle. The causative pathogen was later identified to be Streptococcus dysgalactiae subsp. equisimilis (stG485). Although providing intramuscular injections is an essential skill of health care workers that is performed daily worldwide, it may constitute a port of entry for pathogens via skin breaches that can cause life-threatening infections. All invasive procedures should be carefully performed, especially when immunologically compromised patients are involved.

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