Objective We aimed to evaluate the efficacy of amitriptyline as a therapeutic option for irritable bowel syndrome (IBS) through a meta-analysis of randomized controlled trials.
Methods For the years from 1966 until May 2012, PubMed, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials were searched for double-blind, placebo-controlled trials investigating the efficacy of amitriptyline in the management of IBS.
Results Four randomized, placebo-controlled clinical trials met our criteria and were included in the meta-analysis. The pooled relative risk for clinical improvement with amitriptyline therapy was 4.18 (95% CI: 2.00 to 8.77, p=0.0001).
Conclusion It was thus concluded that amitriptyline exhibits a clinically and statistically significant control of IBS symptoms.

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Objective Albuminuria is thought to reflect generalized endothelial dysfunction. In hypertensive patients, albuminuria increases the risk of cardiovascular disease (CVD) events. Therefore, screening for albuminuria is critical for stratifying risks in hypertensive patients. However, a limited number of Japanese studies have performed quantitative examinations of albuminuria. The objective of this study was to examine the utility of the CLINITEK MICROALB CREATININE TEST for albuminuria screening.
Materials The CLINITEK MICROALB CREATININE TEST consists of a urine test strip that assesses albumin excretion corrected for the urine creatinine levels in only 60 seconds without the need for any special facilities. The CLINITEK MICROALB CREATININE TEST was performed in 5,647 Japanese hypertensive patients, excluding diabetic patients, and the clinical significance of the test was evaluated.
Results According to the CLINITEK MICROALB CREATININE TEST, the A1 (albumin creatinine ratio: ACR <30 mg/g･creatinine), A2 (ACR 30-299 mg/g･creatinine) and A3 (ACR ≥300 mg/g･creatinine) levels of albuminuria were present in 61.2%, 32.5% and 6.3% of the patients surveyed, respectively. The proportions of A2 and A3 patients increased with chronic kidney disease (CKD) stage, blood pressure, age and previous history of CVD. According to a multivariate logistic regression analysis, the A2 and A3 levels of albuminuria were found to be independently associated with a previous history of CVD (odds ratio: 1.36, 95% confidence interval: 1.08-1.72, p<0.01) after adjusting for age, diabetes, blood pressure and estimated glomerular filtration rate (eGFR).
Conclusion In hypertensive patients, the A2 and A3 levels of albuminuria on the CLINITEK MICROALB CREATININE TEST are associated with a previous history of CVD, independent of eGFR. Therefore, by reflecting the status of systemic vascular injury, this test may help to perform CVD risk stratification.

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Objective Shewanella bacteremia is an uncommon but potentially fatal disease. Although hepatobiliary diseases have been proposed to be risk factors for various Shewanella infections, little is known about the features of Shewanella bacteremia in patients with hepatobiliary diseases. This study aims to characterize the presentation and risk factors of Shewanella bacteremia in patients with hepatobiliary diseases.
Methods We retrospectively investigated the clinical features, microbiology and outcomes of patients with Shewanella bacteremia who were admitted to a tertiary medical center between January 2001 and December 2010. All isolates were confirmed to the species level using 16S rRNA sequencing analyses. The English language medical literature was searched for previously published reports.
Results Fifty-nine cases of Shewanella bacteremia, including nine at the hospital, were identified, 28 (47.4%) of which involved underlying hepatobiliary diseases, representing an important risk factor. In 12 of the 28 cases, the infections involved the hepatobiliary system; with a tendency towards an Asian origin. In our case series of nine patients, Shewanella haliotis was isolated in five patients. The majority of our patients lived in coastal areas, consumed seafood regularly and developed bacteremia during the summer season.
Conclusion It is recommended that the possibility for Shewanella infection be considered in patients with bacteremia and also underlying hepatobiliary diseases, particularly if patients present with hepatobiliary infections, a history of seafood, or development of the disease during the summer.

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Objective The aim of this study was to clarify the association between nutritional state on admission and in-hospital death in tuberculosis (TB) patients, including a high proportion of elderly patients.
Methods A retrospective cohort study of 246 TB patients was conducted. The serum albumin concentrations and peripheral blood lymphocyte counts were measured on admission, and the primary outcome of interest was in-hospital death. Patient mortality was categorized into two groups: TB death and non-TB death. A multivariate analysis was performed to evaluate the relationship between nutritional state on admission and in-hospital mortality in TB patients.
Results The median [interquartile range] patient age was 79 [69-83] years, and the in-hospital death rate was 20.73% (TB death: 26 patients; non-TB death: 25 patients). The multivariate analysis revealed that the serum albumin concentrations (OR: 0.21, 95% CI: 0.10-0.41; p<0.0001) and peripheral blood total lymphocyte counts (Category 2 [627.2-1,106.7/mm³] vs. 1 [<627.2/mm³]. OR: 0.28, 95% CI: 0.11-0.73; p=0.009, Category 3 [>1,106.7/mm³] vs. 1. OR: 0.24, 95% CI: 0.08-0.76, p=0.015) on admission were significantly associated with all in-hospital deaths in the TB patients. The serum albumin concentrations and peripheral blood total lymphocyte counts were also found to be associated with in-hospital deaths directly caused by TB.
Conclusion Hypoalbuminemia and lymphocytopenia on admission are predictive risk factors for in-hospital mortality in TB patients. Nutritional defects should thus receive special attention in order to reduce TB patient mortality, particularly among elderly patients.

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The patient was a 40-year-old man who had suffered from Crohn's disease (CD) for 19 years and developed an intractable perianal fistula and two strictures in the small bowel. Dilatation of the two strictures using double-balloon endoscopy did not improve the subileus symptoms. An anal canal adenocarcinoma was also detected using double-balloon endoscopy. The ileum and rectoperianal area were partially resected, and a precise immunohistochemical pathologic assessment revealed that all three lesions were fistula-associated adenocarcinomas. Accumulating endoscopic findings of CD-associated cancer and precise pathologic diagnostic findings will help to establish a suitable surveillance method.

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A 70-year-old man reported dysphagia two months after undergoing thoracic endovascular aortic repair (TEVAR). An endoscopic examination revealed a fistula between the esophagus and the thoracic aortic aneurysm, and computed tomography (CT) showed that the thoracic aortic aneurysm had increased in size. The patient was diagnosed with an aortoesophageal fistula (AEF), and surgical replacement of the thoracic aorta was performed. AEFs are a rare but typically fatal complication after TEVAR. Physicians should consider a diagnosis of AEF and perform endoscopic examinations and CT in patients who undergo TEVAR and subsequently complain of dysphagia.

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We herein report the case of a 62-year-old Japanese man who presented with jaundice, dry eyes and abdominal discomfort. Imaging studies revealed swelling of the periorbital tissue, parotid and submandibular glands, pulmonary hilar lymph nodes, pancreas, bile ducts, gall bladder walls, bilateral kidneys, arterial walls and prostate. A significant increase in the serum level IgG4 was seen, and the patient was diagnosed with IgG4-related disease after undergoing a biopsy of the pancreas and prostate. We herein report a case of IgG4-related disease with multiple ten organ involvement at the onset of the disease that was successfully treated with prednisolone (PSL) therapy.

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An 87-year-old man with a diagnosis of constrictive pericarditis suffered from cough syncope up to 10 times per day on most days during his three-day stay at our hospital. After undergoing a series of treatments (diuretics, codeine and intravenous ceftizoxime), the patient still had a mild cough, although he did not experience any further syncopal episodes associated with coughing. Two months later, the syncopal episodes associated with coughing returned, but at a lower rate.

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A 46-year-old woman was admitted to our hospital for an evaluation of progressive renal insufficiency and elevated liver enzymes. A renal biopsy revealed chronic granulomatous interstitial nephritis. Her laboratory findings indicated primary biliary cirrhosis (PBC), which was confirmed with a liver biopsy. CD4⁺ T cells and CD8⁺ T cells with granuloma formation were the predominant cells infiltrating into the interstitium of the kidneys and liver. The etiology of tubulointerstitial nephritis in the present patient was not clear; however, it might have shared the same pathogenesis as PBC due to the relatively close onset, the similar profiles of infiltrating cells and the presence of granulomas.

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An 84-year-old woman being treated for miliary tuberculosis (TB) with rifampicin (RFP), isoniazid (INH), ethambutol (EB) and corticosteroids suffered from a persistent fever for five months. While tapering the dose of prednisolone, chest computed tomography (CT) revealed diffuse ground glass opacities (GGO) and bronchoalveolar lavage fluid (BALF) showed an increase in lymphocytes. After the anti-TB drugs were discontinued and the dose of the corticosteroids was increased, the CT findings and fever improved considerably. However, readministration of RFP provoked an inflammatory reaction, leading to a diagnosis of RFP-induced pneumonitis. This condition is very rare. This is the first report of RFP-induced pneumonitis occurring during adjunct steroid therapy.

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Three patients with myelodysplastic syndrome (MDS) had absent or extremely low levels of neutrophil alkaline phosphatase (NAP) activity (arbitrarily defined as an NAP score <10). All patients showed varying degrees of hypogranulation in neutrophil morphology. The NAP activity levels transiently normalized following the administration of granulocyte colony-stimulating factor (G-CSF) in two cases. No patients experienced any severe infectious episodes. These results suggest that NAP activity is not central to the neutrophil function.

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A 72-year-old man was admitted with left homonymous hemianopsia and hemiparesis. Magnetic resonance imaging revealed a heterogeneously enhanced lesion in the right parietal lobe. A brain biopsy showed acute demyelination without malignancy, which led to a diagnosis of tumefactive multiple sclerosis (MS). The patient received corticosteroid therapy and experienced clinical and radiological improvement. Six months later, new lesions appeared, and a second biopsy revealed proliferation of dysplastic lymphocytes. This led to a revised diagnosis of primary central nervous system lymphoma (PCNSL). Because PCNSL mimics MS both clinically and radiologically, PCNSL is difficult to diagnose. Performing repeated brain biopsies may therefore be required when PCNSL is strongly suspected.

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Neuromyelitis optica (NMO) is an inflammatory disease of the central nervous system (CNS) that preferentially affects the optic nerves and spinal cord. An autoantibody (NMO-IgG) targeting the aquaporin-4 water channel distinguishes NMO from other inflammatory disorders of the CNS. Recent studies have demonstrated that the area postrema and other circumventricular organs (CVOs) can be targeted in NMO.We herein report the case of a 12-year-old girl who experienced anorexia six months before the onset of NMO. Anorexia caused by hypothalamic or CVO dysfunction may herald the onset of NMO.

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We herein present three consecutive cases of nummular headache treated with Neurotropin (NTP). Case 1: A 71-year-old man developed a headache in a circumscribed area of the left parietal region. Treatment with NTP resolved the pain after three months. Case 2: A 57-year-old woman developed bifocal pain in both temporal regions. NTP therapy slightly relieved the pain, although the headache remained. Case 3: A 39-year-old man developed bifocal pain the left temporal region. Treatment with NTP resolved the pain after five days. The present results suggest that NTP may be effective for treating patients with nummular headaches.

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Acute autonomic sensory and motor neuropathy (AASMN) is characterized by prominent dysautonomia with somatic sensory and motor impartment. Prominent dysautonomia is observed during the early phase of AASMN. We herein describe a case of AASMN that involved prolonged autonomic failure and disturbance of sensation despite a rapid recovery from motor weakness. The early and delayed heart-to-mediastinum ratios on ¹²³I-meta-iodobenzylguanidine myocardial scintigraphy were decreased and improved within seven months. However, orthostatic hypotension was prolonged. These results suggest a differential improvement in the cardiac and vasomotor sympathetic functions.

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We herein report the case of a 41-year-old Japanese man with hereditary diffuse leukoencephalopathy with spheroids (HDLS) who carried the de novo K793T mutation in the colony-stimulating factor 1 receptor gene (CSF1R). He showed a gradual decline of his cognitive and mental functions over the following six months. On brain MRI, a thin corpus callosum with T2- and FLAIR-high signal intensity in the splenium was conspicuous, whereas cerebral deep and periventricular white matter lesions were mild. We propose that a diagnosis of HDLS should be considered in patients with presenile dementia presenting with corpus callosum lesions on MRI, even in cases with a lack of any apparent family history.

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A 71-year-old man with a history of chronic obstructive pulmonary disease (COPD) and silicosis was referred to our hospital for an evaluation of dyspnea. A progressively enlarging cavity found in the patient's left lower lung was associated with a worsening respiratory status. One year after the initial referral, the patient was diagnosed with nontuberculous mycobacterial (NTM) infection. We herein report the case of a patient with a mixed infection of M. kansasii, M. avium complex and M. abscessus, the various organisms having been isolated in succession. Recognizing a diagnosis of mixed pulmonary NTM infection is therefore crucial in patients with underlying diseases.

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Infections caused by Gemella morbillorum are uncommon. This organism is primarily associated with endocarditis and bacteremia and rarely with spondylodiscitis, arthritis, hepatic abscesses and meningitis. Sternal osteomyelitis caused by G. morbillorum has not yet been reported. We herein present a case of sternal osteomyelitis with a mediastinal abscess caused by G. morbillorum that occurred in a 74-year-old diabetic patient following blunt force trauma to the anterior chest wall. The patient was treated successfully with surgical excision and prolonged antibiotic treatment. Early recognition and timely intervention are important for managing life-threatening osteomyelitis of the sternum.

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