Objective Diverticular bleeding is the most common cause of acute lower gastrointestinal bleeding, and its incidence has recently increased. However, the treatment strategy of diverticular bleeding has not yet been established. The aim of the study was to investigate the efficacy of contrast-enhanced computed tomography (CECT) to determine the indication for urgent colonoscopy to achieve hemostasis.
Methods A total of 124 patients diagnosed with diverticular bleeding between 2012 and 2013 in our hospital were analyzed. The clinical behavior, factors related to detecting bleeding diverticula, and risk factors for early rebleeding of diverticular bleeding were evaluated.
Results Clinical behavior: Bleeding diverticula were identified in 23 of 124 (19%) patients and most of them (16/23; 70%) were located in the ascending colon. Hemostasis was achieved in all 23 cases, however, six (26%) developed early rebleeding. Factors for detecting bleeding diverticula: In patients in whom extravasation was detected using CECT, the endoscopic detection rate of bleeding diverticula was 60% (12/20), while bleeding diverticula were detected in only 31% (11/35) of patients in whom extravasation was not detected using CECT (p<0.05). The interval between the first hematochezia and colonoscopy in which the bleeding point was detected by colonoscopy (median 23.5 hours) was shorter than that in which bleeding diverticula were not detected (median 43.6 hours) (p<0.01). Risk factors for short term rebleeding: Using a univariate analysis, atherosclerotic comorbidity, anti-inflammatory drugs including low-dose aspirin, antithrombotic agents, vital signs on admission, hemoglobin level on hospitalization, and extravasation on CECT were not found to be significant risk factors.
Conclusion The finding of extravasation on CECT is the most important factor for identifying and treating bleeding diverticula by colonoscopy. In such cases, urgent colonoscopy is recommended.

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Objective Recent guidelines have adopted an incidence of febrile neutropenia (FN) threshold of 20% for the use of prophylactic granulocyte colony-stimulating factor (G-CSF). In a Japanese phase II study of a combination chemotherapy regimen consisting of oxaliplatin, irinotecan, fluorouracil and leucovorin (FOLFIRINOX) for Japanese patients with advanced pancreatic cancer, the incidence of FN and severe neutropenia were 24.7% and 77.8%, respectively, without G-CSF prophylaxis. The aim of this retrospective study was to investigate the incidence of FN or severe neutropenia induced by full-dose FOLFIRINOX administration with G-CSF prophylaxis during the first cycle of treatment.
Methods Patients with advanced pancreatic cancer who received FOLFIRINOX with G-CSF prophylaxis during the first cycle of treatment from January 2014 to August 2014 were investigated and the frequency of adverse events during the first cycle was measured.
Results Among seven patients who received FOLFIRINOX, six patients met the eligibility criteria. The patient characteristics were as follows: median age (range), 57 (50-66); men/women, 3/3; performance status 0/1, 2/4. Grade 3/4 hematological adverse events were as follows: leukopenia in 33% of the patients, neutropenia in 33% of the patients, thrombocytopenia in 33% of the patients and FN in 17% of the patients. One patient was heterozygous for the UGT1A1*6 and UGT1A1*28 polymorphisms and experienced FN. Grade3/4 non-hematological adverse events were as follows: anorexia in 33% of the cases and nausea in 50% of the cases.
Conclusion Although the present study was retrospective and small, the simultaneous administration of G-CSF might be effective for the prevention of severe neutropenia and FN in patients treated with FOLFIRINOX.

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Objective In the emergency department, it is sometimes difficult to differentiate heart failure (HF) from other diseases (e.g., respiratory diseases) in patients who develop dyspnea. The plasma B-type natriuretic peptide (BNP) levels increase in patients with HF, and various levels are associated with specific New York Heart Association classes. Although the diagnosis of HF should not be made based only on the plasma BNP levels, the identification of a cut-off value for BNP to diagnose HF would be helpful.
Methods Patients admitted to the emergency department of our hospital with dyspnea between January 2010 and December 2011 were retrospectively reviewed. The patients whose estimated glomerular filtration rate was less than 30 mL/min/1.73 m² were excluded. Patients were divided into two groups: those with HF (n=131) and those without HF (n=138). The cut-off value for BNP was determined by the receiver-operating characteristic curve.
Results The area under the curve of this curve was 0.934. The optimal cut-off point for detection of HF was 234 pg/mL. The sensitivity and specificity were 87.0% and 85.5%, respectively. The fifth and 95th percentiles of the HF group were 132.2 and 2,420.8 pg/mL, respectively. Those of the non-HF group were 9.7 and 430.2 pg/mL, respectively.
Conclusion Our study suggests that a plasma BNP level cut-off value of 234 pg/mL can be used to detect HF in the emergency department.

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Objective This retrospective study evaluated the long-term efficacy of sitagliptin and the factors contributing to its glucose-lowering effect.
Methods Six hundred and sixteen dipeptidyl peptidase-4 inhibitor-naïve outpatients with type 2 diabetes who began sitagliptin treatment between December 1, 2009 and December 31, 2011 were included in this study. The inclusion criteria were that the patient had regularly visited our hospital for a period of ≥700 days from the initiation of sitagliptin treatment and the measurement of hemoglobin A1c (HbA1c) had been performed at 0, 3, 6, 12, 18, and 24 months after the initiation of treatment. From the population of 616 patients, 447 and 169 had received sitagliptin for ≥700 and <700 days, respectively. The primary endpoint was ΔHbA1c at 24 months. The factors associated with the hypoglycemic effect of sitagliptin were also investigated.
Results Sitagliptin treatment significantly decreased the level of HbA1c, and the hypoglycemic effect was sustained for at least 2 years. The baseline HbA1c level, duration of diabetes, Δbody weight value, and ΔHbA1c value at 3 months were independently associated with the hypoglycemic effect of sitagliptin.
Conclusion Sitagliptin has a long-term hypoglycemic effect in type 2 diabetes patients. A patient's ΔHbA1c at 3 months may be a predictor of their ΔHbA1c at 24 months.

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Objective Pulmonologists and cardiologists view chest radiographs differently. Lung cancer may therefore go undetected in patients referred to cardiovascular departments. We aimed to determine the clinical benefit of the additional interpretation of chest radiographs by pulmonologists in study involving cardiovascular outpatients.
Methods A retrospective review of chest radiographs of outpatients attending a Japanese cardiovascular hospital between April 2000 and March 2010 was conducted. Lung cancer patients were categorized into 3 groups: group C, patients in whom tumors were detected by a cardiologist at the first visit; group P, patients in whom tumors were detected by the additional interpretation of a chest radiographs by a pulmonologist after a lesion was missed by a cardiologist; and group H, patients from an earlier period in which chest radiographs were only examined by a cardiologist.
Results Cardiologists detected 9 cases of lung cancer in groups C and H from 2,430 and 2,288 radiographs, respectively. Pulmonologists detected 10 cases of lung cancer (group P) and 3 other malignancies that were previously undetected, giving a miss rate of 52.6% for the cardiologists. Tumor diameters were significantly smaller in group P than in group C or H. Furthermore, a significantly higher number of the tumors in group P were of an early stage and resectable, with more superposing structures than in groups C or H.
Conclusion The additional pulmonologist-based interpretations significantly increased the detection rate of operable tumors that mostly corresponded to the early T1 stage; this serves offers a potential clinical benefit in reducing the period of time from patient presentation to the diagnosis of lung cancer.

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Objective This study was performed to analyze the lesion patterns of lacunae-sized infarctions on diffusion-weighted imaging (DWI) findings in the perforating arterial territory, and to determine whether this pattern of satellite lesions affected progressive motor defect (PMD).
Methods Seventy-five patients with acute lacunae-sized infarctions in the perforating arterial territory (pons or territory of the lenticulostriate arteries), which was confirmed by cranial magnetic resonance image (MRI), were enrolled in this study. These patients were divided into PMD (n=30) and non-progressive motor defect (NPMD) (n=45) groups according to the dynamic scores of the National Institutes of Health Stroke Scale (NIHSS) within 7 days after stroke. The lesion patterns of lacunae-sized infarctions were divided into single oval or satellite lesions signs based on DWI. The risk factors of stroke and the clinical characteristics of all the subjects, including neurological deficits, infarction lesion patterns in image, and the condition of the basilar artery, were comparatively analyzed.
Results The constituent ratio of satellite lesions signs [20/30 (66.7%)] in the PMD group was higher than that [10/45 (22.2%)] of the NPMD group (χ²= 6.1, p=0.013). Mean NIHSS scores in the PMD group on admission were higher than that of the NPMD group (4.60±1.40 vs. 3.75±1.2, t=2.81, p=0.003). A logistic regression analysis showed that the pattern of satellite lesions was associated with PMD. 〔odds ratio (OR): 3.0, 95% confidence interval (CI) 1.25-7.17, p=0.014〕.
Conclusion Satellite lesions are one of the features of lacunae-sized infarctions patterns, which might be an independent predictor in DWI findings for PMD in patients with lacunae-sized infarctions in the perforating arterial territory.

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Objective A dengue outbreak occurred in Japan 2014. We investigated the characteristics of dengue infection among Japanese.
Methods We investigated the medical charts retrospectively.
Patients The study participants are patients who came to our clinic between 2008 and 2014.
Results We investigated 4 domestic cases and 46 imported cases of Japanese with laboratory confirmation of dengue. Major symptoms were fever (100%), rash (86%), fatigue (84%), headache (81%), joint pain (66%), muscle pain (49%), and bleeding (6%). A late rash that appeared near the time of fever resolution was observed in 37 cases (74%). A total of 38/43 (88%) cases had low WBC count (<3,500 /μL) during the febrile period, 42/48 (88%) cases had a low platelet (PLT) count (<130×10³/μL), and 44/50 (88%) cases had a C-reactive protein (CRP) <2.0 mg/dL.
Conclusion Patients with a high fever, late rash, fever-associated leukopenia, low PLT count, low CRP, and elevated aminotransferases are generally suspected of having a dengue infection.

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Objective The burden of candidemia is shifting from intensive care units (ICU) to non-ICU settings. This study aimed to define the differences in epidemiology and predictors of death between ICU-acquired candidemia (ICUAC) and non-ICUAC.
Methods We conducted a retrospective study of 80 patients with ICUAC and 147 patients with non-IUCAC at five hospitals.
Results The distribution of Candida species and resistance to antifungal agents did not differ between the ICUAC and non-ICUAC groups. ICUAC patients received more echinocandins and less triazoles, as well as more adequate antifungal therapy than non-ICUAC patients (all p<0.05). ICUAC patients had a significantly higher average acute physiology and chronic health evaluation (APACHE) II score (21.0±7.9 vs. 17.8±8.6; p<0.01), Sequential Organ Failure Assessment score (9.2±5.5 vs. 7.4±3.9; p<0.05) and day-90 mortality rate (52.5% vs. 36.7%; p<0.05) when compared to non-ICUAC patients. Using a multivariate logistic analysis, adequate antifungal therapy was found to be the only protective factor for death in both groups. Respiratory failure supported with invasive mechanical ventilation, renal failure supported with replacement therapy and an APACHE II score ≥20 were independent predictors of death in ICUAC patients, while age ≥60 years, concurrent bacteremia and APACHE II score ≥20 were independent predictors of death in non-ICUAC patients.
Conclusion The Candida species and antifungal resistance profiles in patients with ICUAC were similar to non-ICUAC patients, but led to worse outcomes. The protective and risk factors for death may therefore be relevant for the clinical management of patients with candidemia in ICU and non-ICU settings.

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Anaplastic carcinoma is a rare pancreatic cancer, and the malignant transformation of a heterotopic pancreas is also rare. We herein report a case of an elderly woman with a mass of unknown origin in the abdominal cavity. Computed tomography identified the extent of the tumor but not the organ of origin. The abdominal tumor eventually metastasized to the liver and lung. An autopsy and immunohistochemical examination revealed an anaplastic carcinoma possibly originating in an ectopic pancreas.

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Multiple myeloma presents with various kidney injuries, including cast nephropathy, light chain deposition disease, and amyloidosis. Cast nephropathy is the most common form and mostly consists of monoclonal immunoglobulin light chains with Tamm-Horsfall protein. Immunoglobulin light chain (AL) amyloidosis may affect all compartments of the kidney, but it is rare in the tubuli. We herein present a rare case with rapid progression of renal failure caused by the co-occurrence of intratubular amyloidosis and cast nephropathy due to multiple myeloma. Our case suggests unique amyloidogenic light chain cast, which can form amyloid fibrils under specific tubular fluid conditions, and illustrates the complicated light chain pathophysiology.

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A 68-year-old man was hospitalized and examined for renal impairment. A laboratory analysis showed hypercalcemia. Although the serum parathyroid hormone and serum 1-25(OH)₂ vitamin D3 levels were not elevated, the serum parathyroid hormone-related peptide (PTHrP) level was increased. Immunoelectrophoresis of the urine and bone marrow aspiration indicated multiple myeloma (MM). He was diagnosed with the coexistence of cast nephropathy and light chain deposition disease by a renal biopsy. Notably, PTHrP expression was detected in the myeloma cells based on immunohistochemistry and in situ hybridization. It is therefore important to examine the PTHrP concentration in MM patients with hypercalcemia.

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Small cell lung cancer (SCLC) causes paraneoplastic syndromes, such as diabetes mellitus, by eliciting the expression of various antibodies including anti-glutamate decarboxylase (GAD) antibody. A 62-year-old woman presented to our hospital with a 1-week history of progressive dyspnea and difficulty in walking. Computed tomography showed a tumor obstructing the left bronchus and obstructive lung abscesses with pleural effusions. A biopsy during bronchoscopy revealed SCLC, and the clinical stage was ultimately determined to be IIIB. SCLC was complicated by diabetes mellitus with high titers of serum anti-GAD antibody. An immunohistochemical analysis showed GAD expression in the cancer cells, which is a novel finding.

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Human T-cell lymphotropic virus type-1 (HTLV-1)-associated bronchioloalveolar disorder (HABA) is a specific state with chronic and progressive respiratory symptoms caused by bronchiolar or alveolar disorder characterized by smoldering adult T-cell leukemia or the HTLV-I carrier state. We herein report a rare case of HABA with an initial presentation of mosaic perfusion in the lung. The diagnosis was made according to the results of a flow cytometry analysis of the bronchoalveolar lavage fluid and pathological findings. Clinicians must be careful to recognize that mosaic perfusion may be a radiological finding of HABA.

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Lymphomatoid granulomatosis (LYG) is a rare Epstein-Barr virus-associated lymphoproliferative disorder. The disease lacks specific clinical and radiological manifestations, which may delay a definitive diagnosis. We report the case of a 39-year-old man with pulmonary LYG who presented to a hospital after experiencing three months of fever, weight loss, dry cough and exertional dyspnea. He was initially misdiagnosed with pneumonia, granulomatosis with polyangiitis and infectious mononucleosis due to the non-specific manifestations of the disease. We herein present the clinical and radiological characteristics of this case and discuss the procedure for pathological diagnosis, which will likely help clinicians in making a timely definitive diagnosis of this disease.

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We herein report a case presenting with cerebral venous sinus thrombosis (CVST) associated with primary antiphospholipid syndrome (APS). The patient developed recurrent CVST followed by a hemorrhagic ischemic stroke despite the use of warfarin during the appropriate therapeutic window. Thus, we substituted warfarin to rivaroxaban with prednisolone and obtained a good clinical course. In addition to the effect of prednisolone of inhibiting elevated lupus anticoagulants and the recurrence of arterial thrombosis, rivaroxaban may prevent CVST and inhibit hypercoagulability induced by corticosteroids. The combination of an anti-Xa inhibitor and corticosteroid may be an alternative treatment for CVST and arterial thrombus with warfarin-resistant APS.

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A 64-year-old Japanese woman presented with a three-month history of progressive numbness and weakness of the lower extremities. A neurological examination and nerve conduction study indicated sensorimotor polyneuropathy. Since the serum anti-Hu antibody titer was remarkably elevated, paraneoplastic neurological syndrome was highly suspected. A thoracoscopic biopsy of the hilar lymph nodes, in which ¹⁸F-fluorodeoxyglucose uptake was obviously increased, revealed pathological findings for small-cell lung cancer (SCLC). Subsequently, the patient presented with generalized tonic-clonic seizures, and cerebral MRI showed reversible multifocal brain lesions, considered to reflect paraneoplastic encephalopathy. After two courses of chemotherapy for SCLC, the brain lesions totally disappeared.

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We herein report three cases of Parkinson's disease associated with difficulty in eyelid opening, referred to as apraxia of eyelid opening (AEO), which improved after aripiprazole treatment. In case 1, aripiprazole was administered as a psychiatric treatment. It proved to be effective in AEO with blepharospasm. In case 2 and case 3, the patients experienced AEO without blepharospasm, and a significant improvement was observed after aripiprazole treatment. In this study, the aripiprazole dosage ranged between 3 and 9 mg/day. This is the first report of aripiprazole as a potentially effective treatment for AEO in Parkinson's disease.

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We herein describe the case of a woman with amyotrophic lateral sclerosis (ALS) showing errors in her choice of Japanese kana characters in her mobile text messages and agraphia of the kana in her handwriting in spite of the absence of weakness, ataxia, or apraxia of her hands. Magnetic resonance imaging showed the atrophy of the frontal lobes. Single-photon emission computed tomography revealed hypoperfusion of the frontal lobes including Exner's area. Although patients with bulbar-onset ALS have been reported to show agraphia of handwriting, in this case the basis of her agraphia might have been the disturbance of the pathway converting phones to graphemes in series, by which errors of spelling or writing would appear in any modality of output.

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Fabry disease can cause various neurological manifestations. We describe the case of a Japanese woman with Fabry disease who presented with ischemic stroke, aseptic meningitis, and psychiatric symptoms. The patient had a mutation in intron 4 of her α-galactosidase A gene, which was not detected in her family. This case suggests that Fabry disease should be considered in young patients who exhibit central nervous system symptoms such as ischemic stroke, even if there is no family history of the condition. The episodes of aseptic meningitis and stroke experienced by our patient suggest that persistent inflammation might be the mechanism underlying Fabry disease.

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We herein present a report of three patients with Becker muscular dystrophy in the same family who developed complete atrioventricular block or ventricular tachycardia with severe cardiomyopathy. Our cases became unable to walk in their teens, and were introduced to mechanical ventilation due to respiratory muscle weakness in their twenties and thirties. In all three cases, a medical device such as a permanent cardiac pacemaker or an implantable cardiac defibrillator was considered to be necessary. The duplication of exons 3-4 in the dystrophin gene was detected in two of the patients. In patients with Becker muscular dystrophy, complete atrioventricular block or ventricular tachycardia within a family has rarely been reported. Thus attention should be paid to the possibility of severe arrhythmias in the severe phenotype of Becker muscular dystrophy.

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We herein report the case of a 49-year-old man with clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) associated with Legionnaires' disease due to Legionella pneumophila serogroup 2. Past reports suggest that Legionella infection is frequent in cases of MERS-associated pneumonia. Obtaining an early diagnosis of legionella infection is a challenge, especially if a Legionella pneumophila serogroup other than serogroup 1 contains the causative agent. In this case, the splenial lesion played an important role in recognizing the legionella infection. We suggest that legionella infection should be considered as a differential diagnosis in cases of splenial lesions associated with pneumonia.

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We herein describe the case of a 59-year-old Japanese man with diabetes mellitus who presented with vertebral osteomyelitis caused by Salmonella enterica subspecies enterica serovar Enteritidis. The patient presented with a persistent fever without back pain. Extraintestinal infections of Salmonella species are well known and are often reported in immunocompromised patients; however, they are rare in non-immunosuppressed patients. The protracted course and atypical presentation of osteomyelitis in diabetic adults can lead to major diagnostic delays. Moreover, in recent years, decreased fluoroquinolone susceptibility against salmonellosis has become a problem worldwide, a problem that needs to be urgently addressed.

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A 47-year-old woman presented with persistent dysphagia. A gastroendoscopy revealed massive esophageal candidiasis, and oral miconazole was prescribed. Three weeks later, she returned to our hospital without symptomatic improvement. She was febrile, and blood tests showed leukocytosis (137,150 /μL, blast 85%), anemia and thrombocytopenia. She was diagnosed with acute myeloid leukemia (AML). She received chemotherapy and antimicrobial agents. During the recovery from the nadir, bilateral ocular candidiasis was detected, suggesting the presence of preceding candidemia. Thus, esophageal candidiasis can be an initial manifestation of AML. Thorough examination to detect systemic candidiasis is strongly recommended when neutropenic patients exhibit local candidiasis prior to chemotherapy.

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