A 38-year-old female with systemic lupus erythematosus (SLE) initiated belimumab treatment. One month later, she presented with a reddish painful swelling on her right lower leg.She was treated with ceftriaxone and vancomycin. However, novel erythematous papules and indurated nodules appeared on both her lower legs. Skin biopsy revealed microabscess formation with mixed cell granuloma surrounded by inflammatory cell infiltration within the dermis with subcutaneous fat tissue. A large number of acid-fast bacilli were observed with Ziehl–Neelsen staining. DNA sequencing of both the hsp65 and the 16S rRNA sequences showed a 100% match with the corresponding region of Mycobacterium haemophilum. Mycobacterial culture revealed satellite growth enhancement on Middlebrook 7H11 agar plates around a paper strip containing hemin. She was treated with levofloxacin, rifabutin, and ethambutol. Within 13 months, her cutaneous lesions improved markedly without any side effects. The B cell-targeted biologic belimumab, a fully humanized IgG1γ monoclonal antibody that inactivates B lymphocyte stimulator, has been considered to be beneficial for active SLE. However, this therapy could increase the risk for the development of biologic therapy-associated mycobacterial infections, both tuberculosis and nontuberculous mycobacteria infections.

BACKGROUND/OBJECTIVES: Osteoarthritis (OA) is a major public health issue in Japan and other countries, and foods that prevent or treat OA are in strong demand. Proteins and peptides in chicken meat and bones are known for being rich in functional and nutritional ingredients for the improvement of osteoporosis. We speculated that chicken legs, a food consumed in many regions of the world, may also contain such ingredients. In this study, we aim to (i) evaluate the effect of chicken leg extract (CLE) on the promotion of cartilage matrix production and (ii) identify the active ingredient in CLE that contributes to this function. MATERIALS/METHODS: Artificial CLE digest was prepared, and the acid mucopolysaccharide production-promoting activity of the CLE digest was evaluated by alcian blue staining of ATDC5 cells. CLE was orally administered to rabbits with burr holes in the knee joint of the femur, and the degree of regeneration of cartilage matrix was evaluated. Furthermore, we investigated orally administered CLE-derived peptides in human plasma using LC-MS. From measuring the acid mucopolysaccharide production-promotion activity of these peptides, a molecule considered to be an active ingredient in the CLE digest was identified. RESULTS: CLE digest promoted acid mucopolysaccharide production and facilitated regeneration of cartilage matrix in in vitro and in vivo experiments. Four peptides including phenylalanyl-hydroxyproline (Phe-Hyp) were detected as CLE-derived peptides in human plasma. The effect of CLE was inferred to be due to Phe-Hyp, which was confirmed to be present in the CLE digest. CONCLUSIONS: It was shown that CLE stimulated the production of articular cartilage matrix both in vitro and in vivo, and that CLE could be an effective food for preventing or treating OA. Furthermore, only Phe-Hyp was confirmed as the active compound in the CLE digest, suggesting that the activity of CLE was due to Phe-Hyp.
Alcian Blue ; Cartilage ; Cartilage, Articular ; Chickens ; Femur ; Humans ; In Vitro Techniques ; Japan ; Knee Joint ; Leg ; Meat ; Osteoarthritis ; Osteoporosis ; Peptides ; Plasma ; Public Health ; Rabbits ; Regeneration

BACKGROUND: Sedentary behaviors have recently become an important public health issue. We aimed to investigate the relationship between screen time and nutrient intake in children and adolescents. METHODS: The present study was conducted in 2013. Data were collected from children and adolescents aged between 6 and 15 years old in Shika town. Questionnaires were distributed to 1459 subjects, 1414 of whom participated in the study (96.9%). Sedentary behaviors were assessed based on participants' screen behaviors (television (TV) viewing, personal computer (PC) use, and mobile phone (MP) use). The main outcomes were the intake of nutrients from a validated food frequency questionnaire. Analysis of covariance (ANCOVA) was used to examine the significance of differences in nutrient intake estimates. Multivariate linear regression analyses, adjusting for age, BMI, and physical activity, were used to provide parameter estimates (β) and 95% CI for the relationship between screen time and nutrient intake. RESULTS: In boys, longer TV viewing times correlated or tended to correlate with a lower intake of protein, potassium, calcium, iron, vitamin K, vitamin B-2, and total dietary fiber. In girls, longer TV viewing times correlated with a lower intake of protein, sodium, calcium, vitamin D, and vitamin B-2. Longer TV viewing times correlated with a higher intake of n-6 fatty acids in girls. PC use was related or tended to be related to a lower intake of potassium, iron, vitamin K, and folic acid in boys, but not in girls. A relationship was observed between MP use and a lower intake of vitamin K in boys, and MP use and a higher intake of vitamin D in girls. CONCLUSIONS The present results revealed that longer TV viewing times are associated with less protein, minerals, vitamins, and total dietary fiber intake in children and adolescents. It was also revealed that boys with PC use have less minerals and vitamins. These results support the need to design intervention programs that focus on decreasing TV viewing time in both sexes and PC use in boys while encouraging adherence to dietary guidelines among children and adolescents.
Adolescent ; Body Mass Index ; Child ; Cross-Sectional Studies ; Diet ; Energy Intake ; Exercise ; Female ; Humans ; Japan ; Male ; Screen Time ; Sedentary Behavior ; Sex Factors ; Socioeconomic Factors

OBJECTIVE: The purposes of this study were to assess the clinical features of cardiac auscultatory events in outpatients in general internal medicine, and to make teaching suggestions for education on cardiac auscultatory skills in primary care medicine.
METHODS: The subjects included 104 consecutive outpatients with chest symptoms, and cardiac auscultatory findings were assessed prospectively.
RESULTS: Cardiac auscultatory events were found in 32 (30.8%) among the 104 subjects. The subjects with cardiac auscultatory events were significantly older than those without cardiac auscultatory events (p<0.05) . The cardiac auscultatory events of the 32 subjects were as follows; splitting of the first heart sound in 2 subjects, mid-systolic click in 2 subjects, fourth heart sound in 3 subjects, systolic murmur in 24 subjects (including one subject with both systolic and diastolic murmurs), and diastolic murmur in 2 subjects. Aortic stenosis was diagnosed in 2 subjects, and mitral regurgitation was diagnosed in one subject of the 24 subjects with a systolic murmur. One subject with both systolic and diastolic murmurs was considered to have a relative systolic murmur with aortic regurgitation. The other 20 subjects with a systolic murmur were considered to have innocent murmurs. The 2 subjects with a diastolic murmur were diagnosed as having aortic regurgitation.
CONCLUSIONS: We suggest that the following cardiac ausculatory events should be given educational priority in primary care; 1) Fourth heart sounds as an extra heart sound. 2) Innocent murmurs: characteristics of innocent murmurs and discrimination from systolic murmurs caused by organic heart disease. 3) Systolic murmurs caused by aortic stenosis or mitral regurgitation. 4) Diastolic high-pitched murmurs caused by aortic regurgitation.

We performed entry closure for the chronic type B dissecting aneurysms by open surgical procedure or endovascular stent-graft placement. The purpose of this study is to evaluate the mid-term results of these patients with respect to mortality, morbidity, change of aneurysm diameter and outcome of the false lumen. From 1996 to 2003, entry closure was performed on 8 patients with chronic dissecting aortic aneurysm with an entry site in the descending aorta and visceral arteries that originated from the true lumen. The study population consisted of 4 men and 4 women with a mean age of 63.8±10.9 years. One patient had a DeBakey type III a and 7 patients had a DeBakey type III b dissecting aneurysm. Five patients underwent surgical entry closure and 3 patients underwent endovascular stent-graft placement. The mean follow-up period was 40±29 months. No operative mortalities, complications of paraplegia or visceral ischemia occurred. A leak was identified in 3 patients, 1 patient underwent an open repair with descending aortic replacement and 1 patient required additional stent-grafting. In the follow-up period, 1 patient died of cancer, but there were no dissection-related mortalities or re-operations for increase in size. With the exception of 1 case with a graft replacement, complete thrombosis of the thoracic aortic false lumen was achieved in 6 cases. There were no significant differences in the pre- and postoperative aortic diameter. Overall, complete thrombosis of the thoracic aortic false lumen was achieved with a high rate of success without a dissection-related mortality. Long-term follow-up, however, is necessary because a reduction in size did not occur in some cases.

The total arch replacement protocol using the open-style stent-graft placement is frequently performed for type A aortic dissection to obtain complete closure of entry sites. However the open-style stent-graft placement must be carefully planned when the entry site is in the descending aorta and extends beyond the level of the tracheal bifurcation, because spinal cord ischemia can be caused due to occlusion of lower thoracic intercostal arteries. We report an alternative to total arch replacement for type A aortic dissection with entry in the ascending aorta and aneurysmal re-entry in the descending aorta, beyond the level of the tracheal bifurcation. We inserted a guide-wire from the dissected area of the aortic arch towards the normal region beyond the re-entry in the descending aorta, with confirmation by direct ultrasonography and already incised half, introduced a graft into the descending aorta using the wire as a guide and performed anastomosis at the level of the transverse aortotomy in the inclusion method. This operation has the advantage of preventing spinal cord ischemia because the re-entry site in the descending aorta is confirmed by direct ultrasonography and the distal anastomosis does not reach the lower thoracic intercostal arteries. In this method, by which the prosthesis is introduced through the descending aorta and anastomosed in the inclusion method, is not needed troublesome treatment in the descending aorta and less invasive than conventional single-stage total arch replacement and applicable with the great safe for aortic dissection that had shown difficulty in application of open-style stent-graft placement.

We describe our experience with a left atrial (LA) myxoma in a 15-year-old female who experienced abdominal symptoms so prominent that she was initially thought to have an inflammatory enterocolitis.
The patient's young age and predominant abdominal symptoms in the absence of any cardiac symptoms made it difficult to diagnose the LA myxoma early in the present case. This experience underscores the need for an intensive search for cardiac myxomas in patients with findings suggestive of inflammatory diseases or collagen disorders.

Although the pressure gradient (PG) and the effective orifice area (EOA) have been used as indices of prosthetic valve function, these values show correctly neither energy loss, nor increased workload. This study aimed to evaluate the prosthetic valve function using echocardiography and PG, EOA and energy loss index, a new index advocated by Garcia et al. These were calculated for 40 patients with aortic prosthetic valve replacement by SJM valve (19HP, 6 cases; 21mm, 16 cases; 23mm, 14 cases; 25mm, 4 cases). Preoperative and postoperative echocardiographic measurements and their variations were analyzed and compared according to the size of implanted valve. In the comparison before and after aortic valve replacement, left ventricular mass (383±151g vs 288±113g, p<0.01), SV1+RV5 on ECG (5.07±1.73mV vs 3.83±1.5mV, p<0.01), and diastolic left ventricular posterior wall thickness (14.4±3.7mm vs 12.9±2.8mm, p<0.05) decreased significantly after the operation. However, there was no significant difference according to the size of the prosthetic valve in these reduction rates caluculated by (preoperative value-postoperative value)/preoperative value. Small size prosthetic valves were used for patients with small diameter of left ventricular outflow tract (LVOT) (19HP, 18±2mm; 21mm, 21±2mm; 23mm, 23±4mm; 25mm, 27±3mm; p<0.01) and small body surface area (19HP, 1.5±0.2m²; 21mm, 1.5±0.2m²; 23mm, 1.7±0.1m²; 25mm, 1.8±0.1m²; p<0.01) in our study. There was a signifcant difference in EOA (19HP, 1.2±0.4cm²; 21mm, 1.9±0.7cm²; 23mm, 2.2±0.9cm²; 25mm, 3.5±1.1cm²; p<0.01), but not in ELI (19HP, 1.01±0.41cm²/m²; 21mm, 1.87±1.03cm²/m²; 23mm, 1.83±1.09cm²/m²; 25mm, 3.08±1.21cm²/m²; p=0.055) according to the size of the prosthetic valve. Small size prosthetic valves had small EOA, but showed satisfactory valve function in decreasing left ventricular hypertrophy and reducing LVM and ELI of small size was similar to that of large size.

A 63-year-old woman was admitted to our hospital for combined valvular disease with tricuspid valve stenosis. Aortic and mitral valves were replaced with artificial valves and tricuspid valve were replaced with a biological valve. We chose artificial valves for the aortic and mitral valves because the patient was younger than 70, while a biological valve was used for the tricuspid valve to avoid possible thromboembolism. The postoperative course was excellent. We propose that it is better to use a biological valve for the tricuspid valve, even if artificial valves are used in other sites.

Teaching ambulatory-care medicine is essential for primary-care education. However, few studies of ambulatory-care training have been done in the past decade. We performed a nationwide survey to examine whether and how ambulatory medicine is taught to medical students and residents. We sent questionnaires to all medical schools (n=80) and accredited teaching hospitals (n=389) in February 2001. The response rates were 83.3% and 79.2%, respectively. Fifty-one (78.5%) of the 65 medical schools provided ambulatory-care education, although the programs varied considerably from school to school. Only 104 teaching hospitals (26.7%) had an ambulatory-care training program.