Abstract: Objective While much attention is given to the fifth vital sign, the utility of the 4 classic vital signs (blood pressure, respiratory rate, body temperature, and heart rate) has been neglected. The aim of this study was to assess a possible association between vital signs and the Sequential Organ Failure Assessment (SOFA) score in patients with sepsis. Methods We performed a prospective, observational study of 206 patients with sepsis. Blood pressure, respiratory rate, body temperature, and heart rate were measured on arrival at the hospital. The SOFA score was also determined on the day of admission. Results Bivariate correlation analysis showed that all of the vital signs were correlated with the SOFA score. Multiple regression analysis indicated that decreased values of systolic blood pressure (multivariate regression coefficient [Coef] = -0.030, 95% confidence interval [CI] = -0.046 to -0.013) and diastolic blood pressure (Coef = -0.045, 95% CI = -0.070 to -0.019), increased respiratory rate (Coef = 0.176, 95% CI = 0.112 to 0.240), and increased shock index (Coef = 4.232, 95% CI = 2.401 to 6.062) significantly influenced the SOFA score. Conclusion Increased respiratory rate and shock index were significantly correlated with disease severity in patients with sepsis. Evaluation of these signs may therefore improve early identification of severely ill patients at triage, allowing more aggressive and timely interventions to improve the prognosis of these patients.

Abstract: Objective The aim of this study was to describe the epidemiology, clinical features, antimicrobial treatment, and outcomes of patients with nursing and healthcare-associated pneumonia (NHCAP); a new category of pneumonia proposed by the Japanese Respiratory Society. Methods We conducted a retrospective analysis of a prospectively collected database of patients with NHCAP and community-acquired pneumonia (CAP) hospitalized at a single center between January 2008 and December 2010, and compared their clinical characteristics. The criteria for NHCAP were as follows: (1) residence in a nursing home or an extended-care ward, (2) a discharge from a hospital in the preceding 90 days, (3) an elderly or handicapped patient who needs long-term care, (4) a patient who regularly requires vascular access in an outpatient setting. Results A total of 442 NHCAP patients and 451 CAP patients were evaluated. The NHCAP patients were older and had a higher frequency of underlying diseases. Aspiration was thought to be associated with the NHCAP in 63% of patients. Streptococcus pneumoniae was the leading pathogen in both groups, whereas the frequency of multidrug-resistant pathogens was higher in the NHCAP patients. The most frequently used antimicrobials in NHCAP patients were penicillins with beta-lactamase inhibitors. The in-hospital mortality and recurrence rates were significantly higher in NHCAP patients than in CAP patients (13.1% vs. 5.1%, p<0.001 and 18.8% vs. 5.5%, p<0.001). Conclusion The clinical picture of NHCAP is consistent with that of HCAP described in the past. It is thought to be of benefit to modify the healthcare-associated pneumonia (HCAP) criteria considering the healthcare and social health insurance system in Japan.

Abstract: Objective Eosinophilic esophagitis (EoE) is diagnosed by the presence of dysphagia and intraepithelial eosinophilic infiltration of ≥15 per high-power field (HPF). EoE should be distinguished from proton pump inhibitor-responsive esophageal eosinophilic infiltration (PPI-R EEI) in patients that are responsive to PPI treatment. The aim of this study was to determine the prevalence of EoE and PPI-R EEI in Japanese patients in a multicenter study. Methods Ten hospitals participated in this study. Esophageal biopsy was performed when the patients had typical EoE symptoms or when endoscopic findings revealed a typical EoE appearance. EEI was defined as the intraepithelial eosinophilic infiltration of ≥15 per HPF. Patients with EEI received rabeprazole for 8 weeks to distinguish EoE from PPI-R EEI. Results A total of 13,634 subjects that underwent upper gastrointestinal endoscopy because of further examination or as a routine checkup were enrolled. Seventy-one (0.5%) patients suspected with EoE were examined by biopsy. A histological examination of 7 (9.9%) cases revealed EEI. Two of these 7 patients showed no symptoms and the other 5 were treated with PPI. Two (0.01%) patients were diagnosed with EoE and 3 (0.02%) with PPI-R EEI. Conclusion EoE and PPI-R EEI were rare in Japanese patients that underwent upper gastrointestinal endoscopy.

Abstract: OBJECTIVE The aim of this study is to establish a causal relationship between excess body weight and the onset of diabetes in a retrospective cohort study.

Abstract: OBJECTIVE: To investigate the association between low free triiodothyronine (fT3) levels and the severity and prognosis of patients with acute myocardial infarction. METHODS: A total of 501 patients with acute myocardial infarctions were enrolled in our study. The circulating levels of thyroid hormones and clinical parameters were assayed. The patients were categorized into either the low fT3 group or the normal fT3 group according to the fT3 level on admission. All patients underwent a follow-up for 10±2 months for mortality from any cause and the occurrence of any adverse major cardiac events (MACE). RESULTS: There were 171 patients in the low fT3 group (fT3<3.5 pmol/L) and 330 patients in the normal fT3 group (≥3.5 pmol/L). During the follow-up period, 33 patients died (6.6%) and the overall survival rates were 86.0% and 97.3% in patients with a low fT3 level and a normal fT3 level, respectively. The rates of MACE were 66.7% and 45.5% in the patients with and those without low fT3 levels, respectively. Using a multivariable Cox proportional hazards model, the fT3 level was found to be the most important predictor of cumulative death and MACE (hazard ratio [HR] for death: 0.142, p<0.001 and HR for major adverse cardiac events: 0.748, p=0.007). A Kaplan-Meier analysis revealed that those patients with low fT3 levels had higher rates of MACE and death. CONCLUSION: A low fT3 level, a common phenomenon in patients with acute myocardial infarctions, is a strong predictor of short-term and long-term poor prognoses in patients with acute myocardial infarctions.

Abstract: Background Systemic lupus erythematosus (SLE) has been reported to be associated with an increased risk of cardiovascular disease. However, most studies have been criticized for either a small sample size or the lack of a prospective control. Our study investigated the relationship of SLE and the subsequent development of ischemic stroke using a nationwide, population-based database in an Asian population. Methods From 2000 to 2007, we identified a study cohort consisting of a total of 11,637 newly diagnosed SLE patients using the National Health Insurance Research Database in Taiwan. A control cohort of 58,185 subjects without SLE, matched for age, gender, and comorbidities were selected for comparison to observe the occurrence of ischemic stroke in these two groups. Results During a follow-up period of up to 7 years, ischemic stroke developed in 258 (2.22%) of the patients with SLE and in 873 (1.5%) of patients in the comparison cohort. Kaplan-Meier analysis also revealed a tendency of SLE patients toward ischemic stroke development (log rank test, p = 0.001). After Cox model adjustment for patients' demographic characteristics and selected comorbidities, patients with SLE were found to have a 1.67-fold (95% CI, 1.45 to 1.91) higher risk of developing ischemic stroke. Conclusion Patients with SLE have an increased risk of stroke.

Abstract: Raoultella ornithinolytica is a Gram-negative aerobic bacillus reclassified in the new genus from the Klebsiella species based on new genetic approaches; however, human infections caused by R ornithinolytica are rare We herein report three cases of R ornithinolytica bacteremia associated with biliary tract infections in cancer patients R ornithinolytica can be a causative pathogen of biliary tract infection in cancer patients

Abstract: OBJECTIVE The aim of this hospital-based cohort study was to clarify the independent association between silent brain infarct (SBI) and arterial stiffness indicated by brachial-ankle pulse wave velocity (baPWV) including the cutoff value for SBI. METHODS We studied 240 consecutive patients (mean age 69 years) with no history of stroke. We assessed the presence of SBI, white matter hyperintensities (WMHs), and risk factors. Arterial stiffness was evaluated using baPWV. We measured the intima-media thickness of the common carotid artery (CCAIMT) using carotid ultrasonography. We divided patients into two groups according to the presence or absence of SBI, and compared clinical characteristics between the two groups. RESULTS In multivariable analysis, increased baPWV [by 1 m/s; odds ratio (OR) 1.13, 95% confidence interval (CI) 1.02-1.25] was independently associated with SBI. The baPWV cutoff value for SBI was 17.49 m/s. Patients with baPWV≥17.49 m/s had a higher possibility of the presence of SBI (OR 2.30, 95% CI 1.02-5.34) compared with patients with baPWV <17.49 m/s. Furthermore, the adjusted OR for the presence of SBI of the combination of baPWV≥17.49 m/s and CCAIMT≥1.1 mm (OR 2.73, 95% CI 1.24-6.11) was higher compared with that of baPWV≥17.49 m/s (OR 2.47, 95% CI 1.11-5.65). CONCLUSION Arterial stiffness is independently associated with SBI. Measurement of baPWV can indicate the presence of SBI, especially in patients with baPWV≥17.49 m/s.

Abstract: OBJECTIVE Determining the prognoses of patients with acute ischemic stroke is difficult. Therefore, the aim of this study was to evaluate whether the combined assessment of plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and the National Institutes of Health Stroke Scale (NIHSS) variables is relevant to the prognosis of patients with acute cerebral ischemic infarction in-hospital. METHODS We enrolled 122 patients who were within three days of onset of acute ischemic stroke. We measured the plasma NT-pro-BNP level of each patient within 72 hours and recorded the NIHSS score on admission. The factors associated with death were investigated using a multivariate logistic regression analysis. RESULTS Twenty-three patients (18.85%) died during hospitalization. The frequency of atrial fibrillation (AF), the NIHSS score on admission (8.69±4.87 in the survival group vs. 14.48±2.54 in the deceased group, p 1,583.50 pg/mL) and NIHSS scores on admission (NIHSS >12.5) had a substantially higher mortality rate than those without elevated NT-pro-BNP levels and NIHSS scores (89.47% vs. 9.84%, p 1,583.50 pg/mL (OR, 5.001; 95% CI, 1.233 to 20.287, p=0.024) and a NIHSS score >12.5 (OR, 1.465; 95% CI, 1.191 to 1.801, p<0.001) were each independent factors associated with in-hospital death. CONCLUSION The plasma NT-pro-BNP level and the NIHSS score added independent and incremental contributions to the prognostic stratification of patients with acute ischemic stroke.

Abstract: Objective The present study was undertaken to investigate the role of neck circumference (NC) in predicting prehypertension in children and adolescents. Methods We conducted a cross-sectional study including 6,802 children and adolescents (3,631 boys and 3,171 girls) aged 5-18 years. Main anthropometric data and related information were collected. Results The prevalence of prehypertension was 14.4%, 16.4% and 17.1% in normal weight, overweight and obese group respectively. Among the participants with normal body mass index (BMI), higher NC was significantly associated with increased odds of prehypertension (OR: 1.439; 95% CI: 1.118 to 1.853) after adjustment for age, gender, BMI and WC. Significant associations between NC and either systolic blood pressure (SBP) (β=0.581 mmHg) or diastolic blood pressure (DBP) (β=0.236 mmHg) were found in the linear regression. No significant ORs were observed either in overweight or in obese categories. Conclusion We concluded that additional measure of NC might expand the ability of BMI for the identification of prehypertension in normal weight children and adolescents.

Abstract: Objective The Japan Respiratory Society documented a new category of guidelines for nursing and healthcare-associated pneumonia (NHCAP), which is distinct from community acquired pneumonia (CAP). The objective of this study was to determine the epidemiological differences between NHCAP patients in a teaching university hospital and a community hospital. In addition, to clarify the strategy for treatment of NHCAP, we investigated the role of atypical pathogens. Methods We analyzed 250 NHCAP and 421 CAP cases in a university hospital and 349 NHCAP and 374 CAP cases in a community hospital. Results Patient age and the incidences of poor general condition were significantly higher in the community hospital compared with those in the university hospital. The distribution and frequency of pathogens, especially multidrug-resistant (MDR) pathogens, were significantly different between the two hospitals. Central nervous system disorders, dementia and poor performance status, which was possibility related to aspiration pneumonia, were significantly more frequent in patients with NHCAP compared with those with CAP in both hospitals. Atypical pathogens were detected in a few cases in patients with NHCAP. Conclusion There were many differences in the clinical characteristics between NHCAP patients in a university hospital and a community hospital even for hospitals located in the same area. Aspiration pneumonia was thought to be the main characteristic of NHCAP in both hospitals. Thus, all NHCAP patients did not need the same empiric therapy with a multidrug regimen directed against MDR pathogens. In addition, physicians rarely need to consider atypical pathogens in NHCAP treatment.

Abstract: Objective This is a retrospective study for risk assessment of acute kidney injury after allogeneic hematopoietic stem cell transplantation (allo HSCT) based on the Acute Kidney Injury Network (AKIN) criteria. Methods Two hundred and eighty-nine consecutive patients who received allo HSCT were studied retrospectively to identify the risk factors for AKI according to the AKIN criteria. The incidence of AKI based on AKIN staging and overall survival (OS) was evaluated using Cox proportional hazard regression models treating each AKIN stage as a time-dependent covariate. Patients We identified a total of 180 patients who developed AKI within 100 days after allo HSCT; AKI was classified as stage 1 in 88 patients (30.5%), stage 2 in 46 patients (15.9%) and stage 3 in 46 patients (15.9%). Results Patients who developed stage 3 AKI had a significantly worse survival compared to those who developed no AKI or lower stage AKI (HR: 7.6, 95%CI: 4.8-12.1; p<0.001). Multivariate analysis for risks for developing AKI revealed an episode of sepsis or sinusoidal obstruction syndrome (SOS) and the use of liposomal amphotericin as a major cause of the severe stage of AKI. Conclusion On the basis of our analysis, sepsis, hemorrhagic cystitis, and acute GVHD were associated with severe AKI, and SOS was associated any stage of AKI.

Abstract: Background Previous randomized studies have reported conflicting results on the efficacy of omega-3 fatty acids in preventing atrial fibrillation (AF) recurrences after cardioversion Objective A systematic review and meta-analysis of the role of omega-3 fatty acids in the prevention of atrial fibrillation recurrences after cardioversion was conducted Methods PubMed, Cochrane Library, Elsevier, Science Online database were searched up to the end of January 2012 to identify all of the studies in human subjects that reported the effects of omega-3 fatty acids on the prevention of atrial fibrillation recurrences after cardioversion Results Overall, omega-3 fatty acids had no significant effect on the prevention of AF recurrences after cardioversion (OR: 063,95% CI 035-113; p=012) The heterogeneity among the studies was significant (p=001, I(2)=66%) Subgroup analysis showed that by administering omega-3 fatty acids at least 4 weeks prior to cardioversion and continuing thereafter, the recurrence rate of AF is significantly low (OR: 039, 95% CI 025-061; p Conclusion In the subgroup administered omega-3 fatty acids at least 4 weeks prior to cardioversion and continued thereafter, the recurrence rate of AF was significantly low More double-blind, randomized, placebo-controlled, multicenter studies with high quality and longer follow-up periods are needed to affirm our conclusion

Abstract: Objective There are many reports regarding the course of migraines during pregnancy. However, the prevalence and characteristics of migraines during the postpartum period have not been adequately investigated. We prospectively investigated the patients suffering from migraines over a long postpartum period in an obstetrics department in Japan. Methods We investigated the course of migraines experienced during the postpartum period by patients in a postnatal ward. The patients were surveyed during the first postpartum week and 1, 3, 6 and 12 months after delivery. The patients were provided a headache diary to assess medication use and migraine attack frequency, severity (the faces pain scale) and duration. Results The migraine remission rate was 63%, 83% and 85% during the first, second and third trimesters, respectively. No patient experienced a worsening of headaches during pregnancy. Headache recurrence during the first month after delivery was more frequent in the patients >30 years of age than in those ≤30 years of age (p<0.05). The percentage of women experiencing recurrence at 1, 3, 6 and 12 months after delivery was 63%, 75%, 78% (n=60) and 87.5% (n=40), respectively. In breastfeeding patients, the rates were 50%, 65.8%, 71.1% and 91.7% and in bottle feeding patients, the rates were 86.4%, 90.9%, 95.5% and 81.3%, respectively. Conclusion We found that 85% of the patients with migraines experience remission during pregnancy and that more than 50% experience recurrence during the first month after delivery. Until six months after delivery, breastfeeding is associated with a lower recurrence rate than bottle feeding.

Abstract: A dipeptidyl peptidase (DPP)-4 inhibitor, commonly used to treat patients with type 2 diabetes, has caused concern because of immune system side effects. We report a 48-year-old woman with type 2 diabetes who was diagnosed with rheumatoid arthritis (RA) after continued polyarthritis and an increase in rheumatoid factor up to 86 IU/mL after three months of treatment with sitagliptin, a DPP-4 inhibitor. The shared epitope (SE)-containing human leukocyte antigen (HLA)-DRB1 alleles, which are important predisposing factors for RA, were positive. RA might have been triggered by sitagliptin due to a predisposing condition.

Abstract: Objective Neurological manifestations of Behcet's disease (NB) are serious complications. However, their pathogenesis remains unclear. The current study examined the levels of proinflammatory cytokines, including IL-1β, IL-6, IL-8 and TNF-α, in cerebrospinal fluid (CSF). Methods CSF cytokines were measured using an enzyme-linked immunosorbent assay. CSF was obtained from 17 patients with acute NB, 19 patients with chronic progressive NB and 20 patients with non-inflammatory neurological diseases, including cerebrovascular disease, cervical spondylosis and degenerative diseases. Results CSF total cell counts and polymorph nuclear leukocyte counts were significantly lower in the patients with chronic progressive NB than in those with acute NB. The CSF levels of IL-6 and IL-8 were markedly elevated in the NB patients compared with those measured in the control patients. There were no significant differences in the CSF levels of IL-6 and IL-8 between the patients with acute NB and those with chronic progressive NB. In contrast, there were no significant differences in the CSF levels of IL-1β and TNF-α among the control, acute NB and chronic progressive NB patients. Consistently, the CSF levels of IL-6 and IL-8 were significantly decreased following successful treatment in both acute NB and chronic progressive NB patients, whereas the CSF levels of IL-1β and TNF-α were not changed significantly. Of note, the CSF levels of IL-6 were significantly correlated with the CSF levels of IL-8 in the patients with acute NB (r =0.7647, p =0.0003) but not in the patients with chronic progressive NB (r =0.1343, p =0.5835). Conclusion These results indicate that CSF IL-6 and IL-8 play important roles in the pathogenesis of NB. However, the data also suggest that the mechanisms underlying the elevation of CSF IL-6 and IL-8 might be different in patients with acute NB and those with chronic progressive NB.

Abstract: Objective Red blood cell distribution width (RDW) is a numerical measure of erythrocyte size variation. It has been recently reported to be an independent prognostic marker of heart failure (HF). Previous studies on RDW were mostly designed for middle-aged and elderly patients (60-79 years old), therefore, there is no established limit for super-elderly patients (≥ 80 years old). The purpose of this study was to evaluate RDW as an effective tool to detect fatal HF in super-elderly patients. Methods The medical records and death certificates of 160 consecutive patients admitted to the Department of Cardiology in Juntendo Tokyo Koto Geriatric Medical Center and who died from June 2002 to October 2010 were reviewed. The causes of death were reviewed, and the factors, including RDW, that might have been related to the fatal HF were evaluated using multivariate logistic regression analysis. Results HF was the major cause of death [52 patients (32.5%), 29 females, age 84.0 ± 7.5 years], followed by pneumonia (18.8%, 30/160), and acute myocardial infarction (16.3%, 26/160). The most common cause of HF was atrial fibrillation (36.6%, 19/52), followed by hypertensive heart disease (19.2%, 10/52) and valvular disorders (17.3%, 9/52). The multivariate logistic regression analysis found that a high RDW (≥ 16.5%) was an independent factor related to fatal HF (OR 2.36, 95% CI 1.10, 5.04, p=0.03). Conclusion HF was the major cause of death, and RDW ≥ 6.5 was significantly associated with fatal HF in super-elderly patients.

Abstract: Objective To analyze the incidence rates and risk factors for bacteremia in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD). Methods The records of 898 consecutive patients undergoing dialysis from January 2003 to December 2008 were reviewed retrospectively. Episodes of bacteremia were recorded. China Medical University (Taichung, Taiwan). Results The overall incidence rate of bacteremia was 7.63 per 100 patient-years in HD patients and 3.56 per 100 patient-years in PD patients and it was higher in HD patients each year from 2003 to 2008. S. aureus (27.53%) was the most common pathogen in HD patients, whereas Coagulase-negative Staphylococcus (21.3%) was the most common pathogen in PD patients. Vascular access infection was the most common etiology in HD patients, whereas peritonitis was the most common etiology in PD patients. Older age, shorter dialysis vintage, use of HD rather than PD, current smoker, use of a venous dialysis catheter, presence of diabetes mellitus, higher comorbidity score, and lower serum albumin were significant risk factors for bacteremia. Diabetes mellitus and lower serum albumin were significant risk factors for bacteremia-associated mortality. Conclusion Placement of a permanent access (fistula, graft, or PD catheter) prior to initiation of dialysis, smoking cessation, and better nutritional status (i.e. higher serum albumin) were associated with a reduced risk of bacteremia in dialysis patients. Higher serum albumin was also associated with a reduced bacteremia-associated mortality.

Abstract: Objective To investigate the impact of metabolic and lifestyle factors on erosive esophagitis in young adults. Methods A total of 5,069 people under the age of 40 years old were enrolled in a medical survey at our institute. People with a previous history of upper gastrointestinal tract surgery were excluded, as were individuals taking medication for reflux symptoms, peptic ulcers, or malignancies. Independent and significant predictors affecting the presence of erosive esophagitis were determined by multivariate analysis. Results A total of 4,990 participants (male/female; 3,871/1,119, age; 33.9±3.9 years) were eligible. A total of 728 participants (14.6%) had erosive esophagitis. Male gender and increasing age were independent predictors for increased prevalence of erosive esophagitis (odds ratio=2.242 and 1.045. 95% confidence interval=1.613-3.117 and 1.019-1.072; p<0.001 and 0.001, respectively). Moderate-to-heavy alcohol consumption, light-to-moderate-to-heavy smoking, hypertension, hyperglycemia, and hiatal hernia each significantly and independently increased the risk for erosive esophagitis (odds ratio=1.499, 1.398, 1.353, 1.570, 1.884, 1.297, 1.562, and 3.213. 95% confidence interval=1.181-1.903, 1.040-1.880, 1.094-1.675, 1.250-1.971, 1.307-2.716, 1.074-1.566, 1.063-2.295, and 2.712-3.807; p=0.001, 0.027, 0.005, <0.001, 0.001, <0.001, 0.007, 0.023, and <0.001 respectively). Helicobacter pylori infection decreased the risk for erosive esophagitis (odds ratio=0.575, 95% confidence interval =0.436-0.759 p<0.001). Neither body mass index nor waist girth conferred increased risk of erosive esophagitis after adjusting for potential confounding factors. Conclusion Risk of erosive esophagitis in Japanese young adults was not increased by obesity, but it was increased by hiatal hernia and metabolic and lifestyle profiles including hypertension, hyperglycemia, alcohol consumption and smoking.

Abstract: Haff disease, first identified in Europe, is unexplained rhabdomyolysis in a person who ingested fish within the 24 hours before onset of illness. Cases of Haff disease after the consumption of fresh water fish have never been reported in China but have been frequently reported from the Baltic region. We first describe five cases of muscle weakness and rhabdomyolysis that occurred after eating crayfish in China and discuss the different epidemiologic and etiologic aspects of this disease.

Abstract: Objective Bacillus cereus (B. cereus) septicemia is a cause of life-threatening infection in patients with hematologic diseases. However, preventing a fatal prognosis in patients with B. cereus infection has not yet been achieved due to insufficient clinical investigations. To discover more optimal treatment strategies, we analyzed B. cereus septicemia in patients with hematologic diseases. Methods At our institution, we observed 13 cases of B. cereus septicemia in 12 patients with hematologic diseases between January 2001 and September 2010. The susceptibility of B. cereus strains to antibiotics was also analyzed. Results Of 12 patients, four died of B. cereus septicemia. In this study, the delayed administration of appropriate antibiotics (starting >24 hours after presentation), the presence of liver dysfunction and evidence of central nervous system (CNS) involvement tended to result in a fatal prognosis. All of the bacterial strains were found to be susceptible to vancomycin and quinolones (such as ciprofloxacin and levofloxacin), whereas many strains were resistant to clindamycin (76.9%) and imipenem (30.8%). In seven of 10 patients, central venous (CV) catheter tips were removed and routinely cultured. Catheter tip cultures were positive for B. cereus in three of seven patients. Conclusion Although not specific to B. cereus bacteremia, patients who died of B. cereus tended to present with CNS symptoms and/or liver dysfunction. Our clinical data suggested that carbapenem and clindamycin are no longer appropriate choices for treating B. cereus. In addition, B. cereus septicemia was found to frequently originate from CV catheters. Constant attention must be paid to update assessments of antibiotic susceptibility and careful management must be applied to CV catheters in patients with hematologic diseases.

Abstract: Objective We conducted a cohort study to identify the risk factors for vitamin D deficiency in predialyzed patients with chronic kidney disease (CKD) Methods An observational study of 135 outpatients with stage 3-5 CKD was undertaken Clinical and biochemical parameters were analyzed in terms of nutritional status, inflammation, and mineral metabolism in relation to serum levels of 25-hydroxyvitamin D [25(OH)D] Levels of 25(OH)D lower than 15 ng/mL were considered to be deficient Results The 25(OH)D-deficient group had a higher body mass index (241±42 kg/m2 vs 225±40 kg/m2, p=00322), and had more diabetic patients (279% vs 36%, p=00003) The multivariate analysis revealed that body mass index (odds ratio=2758; 95% CI, 1048-7721; p=00398), the presence of diabetes (odds ratio=7792; 95% CI, 1808-55439; p=00043), lower hemoglobin concentration (odds ratio=0297; 95% CI, 0099-8732; p=0821), higher serum levels of non-HDL cholesterol (odds ratio=3570; 95% CI, 1449-9442; p=00053) and triglyceride (odds ratio=2447; 95% CI, 0779-1776; p=00258) were the factors associated with low 25(OH)D levels Conclusion Vitamin D deficiency was common among the predialysis CKD patients, and the factors identified as being associated with vitamin D deficiency were diabetes and obesity

Abstract: Objective Local recurrence after radiofrequency ablation (RFA) is a major problem that needs to resolved to increase the survival rate of hepatocellular carcinoma (HCC). CE-US with Sonazoid®, the second-generation contrast media, can detect smaller HCC lesions and the detection rate of ultrasonically unrecognized hypervascular HCC was improved by CE-US. The aim of the present study was to evaluate the role of CE-US with Sonazoid® in improving radicality and reducing local recurrence after RFA for HCC. Patients and Methods A total of 102 nodules treated by RFA at our hospital from January 2006 to October 2009 were enrolled: 31 nodules were treated without CE-US, since CE-US was not yet available (Group A), and 71 nodules were treated with a combination of RFA and CE-US with Sonazoid® (Group B). Results The clinical characteristics (sex, virus marker, Child-Pugh grade, with or without transcatheter arterial infusion chemotherapy with lipiodol, and T factor) did not differ significantly between group A and group B. Mean age was significantly older and tumor size was significantly larger in group B. Group B had significantly better radicality compared with group A. The non-local recurrence rate was significantly higher in group B as compared with group A. Conclusion CE-US with Sonazoid® greatly helps to improve RFA efficacy in HCC treatment. We suggest that the ability of CE-US with Sonazoid® to detect an accurate area of HCC before RFA and to immediately detect a residual tumor during RFA might contribute to an increase of the radicality and reduction of local recurrence after RFA.

Abstract: We describe a case of a 67-year-old man with systemic lupus erythematosus who presented with progressive left hemiplegia. Although the cerebral spinal fluid (CSF) polymerase chain reaction (PCR) for the JC virus was negative, a brain biopsy confirmed the diagnosis of progressive multifocal leukoencephalopathy (PML). The tapering of prednisone and the use of cidofovir could not arrest the disease progression. Administration of mefloquine stopped the extension of the lesion, and resulted in obvious clinical improvement. The CSF nested PCR for the JC virus also became negative. This widely used drug should be tried for the treatment of non-HIV PML.

Abstract: BACKGROUND: Systemic thermal therapy (STT) has been associated with beneficial effects in patients with chronic heart failure (CHF). The fact, however, that it requires a dedicated as well as spacious facility and trained personnel makes it difficult to practice in the daily care of patients with CHF. OBJECTIVE: The aim of this study was to determine whether the leg thermal therapy (LTT) has a positive impact similar to that of STT in patients with CHF. Methods and Results Twenty patients with CHF (57 ± 17 years old, left ventricular ejection fraction=30 ± 10%) received LTT (45°C) for 20 minutes. Immediately after the treatment, the core temperature had increased (+0.3 ± 0.3°C) (p<0.01). While the LTT had no significant effects on the heart rate, systolic arterial pressure, and diastolic blood pressure, it increased the cardiac output (mixed venous oxygen saturation; +2 ± 3%) and decrease the pulmonary capillary wedge pressure (-2 ± 2 mmHg). The LTT significantly improved the flow-mediated vasodilatation (FMD) from 4.8 ± 2.6 to 7.1 ± 3.6%, the antioxidative markers, thiol from 4.0 ± 0.7 to 4.5 ± 0.9 μmoL/g, and the marker of oxidative deoxyribonucleic acid (DNA) damage, urine 8-hydroxy-2'deoxyguanosine (8OHdG) from 100 to 82 ± 3%, respectively (p<0.05). No patient had any adverse effects associated with LTT. Conclusion LTT acutely improved FMD, and oxidative stress in patients with CHF. Although the long-term effect of LTT remains to be investigated, its practicality which is comparable to that of STT would make it an attractive therapeutic strategy for patients with CHF.

Abstract: Objective We conducted a cohort study to investigate whether diastolic function could predict cardiovascular (CV) events in 161 HD patients with preserved systolic function. Materials and Methods The ratio of early transmitral flow velocity to early mitral annular velocity (E/E') was measured by tissue Doppler imaging. Patients were stratified into two groups based on whether they experienced a CV event. Results During a 4-year follow-up period, 64 patients experienced a CV event. The E/E' values (15.18 ± 5.78) in the CV-event group were significantly higher than in the group who had not experienced a CV event (12.32 ± 4.23). Kaplan-Meier analysis indicated that the incidence of CV events was significantly higher in the group of patients whose E/E' was >15 than in the group whose E/E' was ≤15 (log-rank p=0.0016). Multivariate Cox proportional hazards regression analysis revealed the E/E' ratio to be a significant predictor of CV events in HD patients with preserved LV systolic function. Conclusion The results of this study showed that elevated E/E' ratio in chronic HD patients predicts CV events better than other echocardiographic parameters.

Abstract: We report a case of elderly-onset neuromyelitis optica (NMO) positive for the anti-aquaporin-4 (AQP-4) antibody; symptoms developed after the diagnosis of prostate adenocarcinoma and relapsed after a 23-valent pneumococcal polysaccharide vaccination. We suggest that activation of CD4-positive T cells and secretion of interferon-gamma induced by adenocarcinoma and complement activation induced by vaccination are responsible for the onset and relapse of NMO, even if a patient is positive for the anti-AQP-4 antibody. This case supports the previous experimental finding that the anti-AQP-4 antibody does not cause NMO-like lesions when injected alone, but does so after the induction of T cell-mediated experimental autoimmune encephalomyelitis or when co-injected with human complement.

Abstract: Objective β-adrenergic antagonists (β-blockers) are often used to attenuate the hyperadrenergic symptoms of Graves' disease (GD), including palpitation. Although β-blockers reduce the heart rate, cardiac output and oxygen consumption, no firm evidence exists regarding the effects of combined therapy with β-blockers and anti-thyroid drugs. The objective is to elucidate the effects of β-blockers on anti-thyroid drug therapy in GD. Methods Patients newly diagnosed with mild GD were randomly assigned to receive methimazole with or without β-blockers in a prospective multi-center survey. The heart rate and thyroid function were measured and the quality of life was assessed using original and SF-36 questionnaires at 0 and 4 weeks. Results A total of 28 patients were enrolled in the study. Fourteen patients (one man, 13 women) were randomly assigned to the group treated with β-blockers and 14 patients (one man, 13 women) were randomly assigned to the group not treated with β-blockers. Although no significant differences in the improvement of thyroid function were observed between the two groups, the heart rates improved more significantly in the group treated with β-blockers. Specific symptoms, such as easy fatigability and shortness of breath, also improved more significantly with the β-blocker treatment. In addition, 'physical functioning' assessed with the SF-36 questionnaires significantly improved only in the group treated with β-blockers. Conclusion Although β-blockers may not reinforce the effects of anti-thyroid drugs on thyroid function, at least during the course of one month, they are effective in reducing heart rates and ameliorating specific symptoms in patients with mild GD.

Abstract: A 23-year-old woman was admitted with complaints of swelling and pain in the left breast, fever, polyarthralgia and erythema nodosum. A fine-needle biopsy of the mass in the left breast revealed non-caseous granulomatous lobulitis. A diagnosis of granulomatous mastitis was thus made. The administration of prednisolone 40 mg/day resulted in the resolution of the patient's symptoms, and the breast mass thereafter decreased in size. The mass relapsed during the subsequent prednisolone taper. Additional therapy with methotrexate resulted in complete remission. Granulomatous mastitis should therefore be included in the differential diagnosis of polyarthralgia.