Functional dyspepsia (FD) is a functional gastroduodenal disorder presenting with dyspeptic symptoms such as postprandial fullness, early satiety, epigastric burning, or epigastric pain in the absence of organic disease. The factors supposed to be related with symptom generation are delayed gastric emptying, impaired accommodation of the proximal stomach, abnormal gastric acid secretions, visceral hypersensitivity, and psychological factors. If H. pylori is positive, eradication treatment is recommended. The evidence-based clinical practice guideline for FD recently developed by The Japanese Society of Gastroenterology (JSGE) proposed a two-step pharmacological treatment. The first-line treatment includes prokinetic agents or acid suppression therapy. If initial treatment fails, anxiolytics, antidepressants, or traditional Japanese herbal medicine can be employed.

Myasthenia gravis (MG) is an auto-immune disorder caused by neuromuscular transmission failure, and is a representative post-neuromuscular junctional disorder. The most common auto-immune antibody is the anti-acetylcholine receptor (AChR) antibody, which is detected in approximately 80 to 85% of MG patients. Recently, auto-immune antibodies against the muscle-specific receptor tyrosine kinase (MuSK) and the LDL-receptor related protein 4 (Lrp4) have also been found. The clinical symptoms and therapeutic responses are highly dependent on the types of auto-immune antibodies. Thymectomy is a common treatment for MG, although a recent meta-analysis on thymectomy did not show any clinical benefit. Several new immune-mediated therapies have become available and the therapeutic strategy is currently changing drastically. In the future, the establishment of a novel therapeutic strategy is expected for this disorder.

Background:

Although diagnosis of isolated acute vestibular syndrome (AVS) via physical examination has been reported, a great deal of experience is needed to interpret the results. Patients with AVS often cannot participate in a physical examination, and not every emergency department (ED) is equipped with a magnetic resonance imaging machine. Therefore, in isolated AVS, clinical factors other than those used by general physicians and/or residents are required to identify strokes in these patients. The aim of this study was to determine those clinical factors useful in differentiating stroke patients from isolated AVS patients in the ED setting.

Methods:

We examined the records of 116 consecutive patients who presented to the ED between May 2010 and April 2013 with AVS (acute vertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) and without auditory symptoms, head and/or neck pain, or neurological findings. Patients underwent diagnostic neuroimaging. Clinical characteristics and vital signs measured in the ambulance were assessed. Multivariate logistic regression analysis was performed to evaluate the associations of systolic blood pressure (SBP) ≥150 mmHg, diastolic blood pressure (DBP) ≥85 mmHg, heart rate, age ≥60 years, and dyslipidemia with stroke.

Results:

Stroke was diagnosed in eight of the 116 (6.9%) patients with isolated AVS. DBP ≥85 mmHg (odds ratio 29.0; 95% confidence interval 3.38–249) was the only significant and independent factor associated with stroke among patients with isolated AVS.

Conclusion:

This study identified DBP ≥85 mmHg to be a simple and useful clinical factor differentiating stroke from non-stroke isolated AVS.

Background:

Medical interview of patients can yield clues for the detection of thyroid dysfunction. However, symptoms of thyrotoxicosis as described in textbooks are based on Western populations.

Aim:

To elucidate specific symptoms of thyrotoxicosis in Japanese patients.

Methods:

For one year, consecutive patients who visited us for their first medical examination were asked to complete an original questionnaire about their overall complaints.

Results:

Excluding patients who were already being treated for thyroid dysfunction, 267 subjects were analyzed: 67 overt hyperthyroid patients (T), 11 with subclinical hyperthyroidism (ST), 30 hypothyroid patients (H), 25 with subclinical hypothyroidism (SH), and 134 euthyroid subjects (E). Seven symptoms were cited by more than 70% of the patients in T and four were cited by more than 70% of subjects in ST. However, more than half of the subjects in E cited ‘heat intolerance’ and ‘easy fatigability’, indicating that these are considered as nonspecific and indefinite complaints to detect thyrotoxicosis. The mean severity of 19 symptoms was significantly higher in T than in E, and ROC analysis was moderately accurate at distinguishing T from E in four symptoms of ‘palpitation’, ‘shortness of breath’, ‘body weight loss’, and ‘tremor’.

Conclusions:

Four symptoms — ‘palpitation’, ‘shortness of breath’, ‘body weight loss’, and ‘tremor’ — are thought be the most useful for efficiently detecting thyrotoxicosis.

Toxic epidermal necrolysis (TEN) is a rare life-threatening disorder. Although its treatment is not standardised due to the unknown pathogenesis and the lack of randomized clinical trials, systemic corticosteroids, immunoglobulins (IVIG) and immunosuppressive drugs such as cyclophosphamide have been used in the treatment of TEN with some success. We present a case with severe TEN treated successfully with combination therapy including plasma exchange. Although it is expensive and requires venous access, use of plasma exchange may be an effective measure leading to rapid cessation of dermal necrolysis, by the removal of inflammatory cytokines, autoantibodies, immune complex or other unknown toxic substances.

A 70-year-old Japanese woman was referred to our hospital with productive cough and recurrent respiratory infections. She underwent a thymectomy nine years previously for a thymoma. Based on a three-year history of repeated respiratory infections and the presence of hypogammaglobulinemia, a diagnosis of Good syndrome was made. We reviewed forty-six reported Japanese Good syndrome cases. The most commonly infected sites were the lungs, blood, and digestive tracts. Cases with preceding thymoma required a median time of three years (25th and 75th percentile: 1 and 7 years) until hypogammaglobulinemia emerged. The present case showed that Good syndrome should be considered even after a long time period following thymectomy.

A 70-year-old woman was admitted to a respiratory department because of bilateral inguinal lymphadenopathy, mediastinal lymphadenopathy, and re-growth of a nodule in the left lower lobe, which had been identified one year earlier but had regressed spontaneously over the next 6 months. After diagnostic procedures to obtain tissue from the lung and lymph nodes, she was diagnosed with Epstein-Barr virus-negative diffuse large B-cell lymphoma (DLBCL). Spontaneous regression or remission of lung involvement in a patient with DLBCL has rarely been reported and the precise mechanism is unknown, but this case clearly demonstrated regression and re-growth of the lung nodules during her clinical course.

Objective:

Pelvic organ prolapse (POP) is not uncommon in multi-parous or elderly women. One mechanism that may be responsible for renal failure in the presence of POP is chronic retention due to bladder outlet obstruction. We herein presented a case of neglected severe POP in a 60-year-old patient that resulted in renal failure.

Case:

A 60-year-old Japanese woman had a sensation of a vulvar mass since the age of 40. She had general malaise, reduced appetite, and weight loss, but did not exhibit any urinary symptoms or a vulvar mass. Computed tomography (CT) revealed a vulvar mass, and the patient was diagnosed with POP-Q (pelvic organ prolapse quantification) stage 4 following a pelvic examination. A blood examination showed an increased inflammatory response (number of leukocytes 24,600/μl, C-reactive protein 29.10 mg/dl) and renal dysfunction (creatinine 6.40 mg/dl, blood urea nitrogen 83.5 mg/dl). She was initially treated with bladder drainage and antibacterial therapy. Seven months after the initiation of bladder drainage, colpocleisis and urethroplasty were performed following the manual repositioning of POP.

Conclusion:

This patient may have avoided long-term hospital care if she had undergone a gynecological examination earlier. General physicians need to consider POP and learn to perform a basic gynecological examination when examining older women, who are more likely to ignore or conceal symptoms, similar to this case.