Hospitals In Osaka Research Articles

Characterization of the Plasmidome Encoding Carbapenemase and Mechanisms for Dissemination of Carbapenem-Resistant Enterobacteriaceae.

Carbapenem-resistant Enterobacteriaceae (CRE) infections, high in morbidity and mortality, pose serious clinical challenges due to limited treatment options. A previous CRE surveillance study on 1,507 patients from 43 hospitals in Osaka, Japan, revealed that 12% of patients carried CRE and that 95% of the CRE isolates were IMP-type carbapenemase producers. Here, the mechanisms for this regional dissemination of a single carbapenemase gene were investigated. Since the dissemination of CRE is primarily due to the transmission of carbapenemase genes located on plasmids, we analyzed the plasmidome of 230 CRE isolates carrying bla IMP by whole-genome sequencing and Southern blotting. bla IMP-6 was found to be predominantly disseminated among chromosomally distinct isolates through the pKPI-6 plasmid. Underlying the vast clonal dissemination of pKPI-6, various subpopulations deriving from pKPI-6 were identified, which had acquired advantages for the dissemination of CRE isolates. A cluster exhibiting heteroresistance against meropenem by the transcriptional regulation of bla IMP-6 caused an outbreak likely through covert transmission of bla IMP-6 For stable carriage of bla IMP-6, they occasionally integrated bla IMP-6 on their chromosomes. In addition, we detected one isolate that broadened the range of antimicrobial resistance through a single point mutation in bla IMP-6 on pKPI-6. Multifaceted analysis of the plasmidome granted us more accurate perspectives on the horizontal spread of CRE isolates, which is difficult to trace only by comparing the whole genomes. This study revealed the predominant spread of a specific carbapenemase-encoding plasmid accompanying the emergence of phenotypically diverse derivatives, which may facilitate further dissemination of CRE in various environments.IMPORTANCE Global dissemination of carbapenem-resistant Enterobacteriaceae (CRE) threatens human health by limiting the efficacy of antibiotics even against common bacterial infections. Carbapenem resistance, mainly due to carbapenemase, is generally encoded on plasmids and is spread across bacterial species by conjugation. Most CRE epidemiological studies have analyzed whole genomes or only contigs of CRE isolates. Here, plasmidome analysis on 230 CRE isolates carrying bla IMP was performed to shed light into the dissemination of a single carbapenemase gene in Osaka, Japan. The predominant dissemination of bla IMP-6 by the pKPI-6 plasmid among genetically distinct isolates was revealed, as well as the emergences of pKPI-6 derivatives that acquired advantages for further disseminations. Underlying vast clonal dissemination of a carbapenemase-encoding plasmid, heteroresistance was found in CRE offspring, which was generated by the transcriptional regulation of bla IMP-6, stabilization of bla IMP-6 through chromosomal integration, or broadened antimicrobial resistance due to a single point mutation in bla IMP-6.

440-P: Decreased Peripheral Perfusion Measured by Perfusion Index Is a Novel Indicator for Cardiovascular Death in Patients with Type 2 Diabetes and Established Cardiovascular Disease

We investigated the role of peripheral perfusion as an indicator for cardiovascular death in patients with type 2 diabetes and established cardiovascular disease (CVD). This retrospective cohort study included 1080 patients with type 2 diabetes and history of CVD recruited from the outpatient clinic at Matsushita Memorial Hospital in Osaka, Japan. Peripheral perfusion is assessed using the perfusion index (PI), which represents the level of circulation through peripheral tissues. PI was measured using a Masimo SET Radical-7 (Masimo Corporation, Irvine, CA) instrument. The median age and PI values were 74 years (range: 67-79 years) and 2.6% (range: 1.1-4.3%), respectively. The average duration of follow up was 871 ± 265 days. During follow-up duration, 60 patients died due to CVD. The adjusted Cox regression analysis demonstrated that the risk of developing cardiovascular death was higher in the first quartile (HR, 5.84; 95% CI, 2.23 to 20.16) or second quartile (HR, 3.00; 95% CI, 1.05 to 10.81) of PI than that in the highest quartile (fourth quartile) of PI. PI (per 1% decrease) was associated with the development of cardiovascular death (HR, 1.38; 95% CI, 1.15 to 1.64). PI could be a novel indicator of cardiovascular death in patients with type 2 diabetes and established CVD. Disclosure H. Okada: None. Y. Okada: None. M. Fukui: None.

Risk factors for hepatocellular carcinoma in treated chronic hepatitis C patients-Relationship to smoking and alcohol.

Background and AimThe purpose of this study was to identify lifestyle risk factors, such as cigarette smoking and alcohol consumption, in relation to the development of hepatocellular carcinoma (HCC) among chronic hepatitis C patients who have achieved a sustained virologic response (SVR).MethodsThis cross‐sectional study was conducted between 2014 and 2017 using self‐administered questionnaires and medical information at two tertiary hospitals in Osaka, Japan. Study subjects were chronic hepatitis C patients who had achieved SVR without HCC following antiviral treatment that was completed more than 1 year earlier. A logistic regression model was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the development of post‐SVR HCC for each factor.ResultsOf 202 participants, 18 patients were diagnosed with post‐SVR HCC. After considering potential confounders, former drinkers at the time of SVR (OR, 9.51; 95% CI, 1.08–83.90) and patients with a history of gastric or duodenal ulcer (OR, 4.14; 95% CI, 1.37–12.46) were significantly associated with HCC. In addition, among patients with severe fibrosis, current smokers at the time of SVR had an increased OR for HCC compared with never smokers, with marginal significance (OR, 5.61; 95% CI, 0.97–32.63).ConclusionsIn chronic hepatitis C patients with severe fibrosis, continuing smoking after achieving SVR could be a risk factor for post‐SVR HCC. The relationship between gastric or duodenal ulcer history and post‐SVR HCC should be investigated further.

Peripheral perfusion, measured by perfusion index, is a novel indicator for renal events in patients with type 2 diabetes mellitus

Diabetic kidney disease (DKD) is one of the leading causes of end stage renal disease. Despite recent therapies, mortality due to DKD and resources spent on healthcare are important problems. Thus, appropriate markers are needed to predict renal outcomes. Therefore, we investigated the role of peripheral perfusion as an indicator for renal events in patients with type 2 diabetes mellitus. This retrospective cohort study included 566 patients who were admitted to Matsushita Memorial Hospital in Osaka, Japan for type 2 diabetes mellitus. Peripheral perfusion was assessed using perfusion index (PI), which represents the level of circulation through peripheral tissues and was measured on each toe using a Masimo SET Radical-7 (Masimo Corporation, Irvine, CA, USA) instrument. The duration of follow up was 3.0 years. The median age of patients was 70 years (IQR range: 61–77 years) and median PI value was 2.9% (IQR range: 1.8–4.8%). Multiple logistic regression analyses showed that PI (per 1% increase) was associated with an odds ratio of composite of end-stage renal disease (ESRD) and/or doubling of serum creatinine level; n = 40 (odds ratio 0.823 [95% CI: 0.680–0.970]), and composite of ESRD, doubling of serum creatinine level, and renal death and/or cardiovascular death; n = 44 (odds ratio 0.803 [95% CI: 0.665–0.944]). The factors which were statistically significant in univariate analysis and those known to be related factors for renal event were considered simultaneously as independent variables for multiple logistic regression analysis. PI can be a novel indicator for renal events in patients with type 2 diabetes mellitus.

Decreased microcirculatory function measured by perfusion index is predictive of cardiovascular death.

The importance of microcirculation for adverse outcomes in the early phase of critical illnesses has been reported. Microcirculatory function is assessed using the perfusion index (PI), which represents the level of circulation through peripheral tissues. We investigated the correlation between PI and cardiovascular death to explore whether it can serve as a predictor of cardiovascular death. This retrospective study included 2171 patients admitted to Matsushita Memorial Hospital in Osaka, Japan, for medical treatment. We measured PI for all patients. To examine the effects of PI on cardiovascular death, a Cox proportional hazard model was used. The median age and PI values were 72years (range 63-79years) and 2.7% (range 1.4-4.6%), respectively. During the 3927.7 person-years follow-up period, a total of 54 patients died due to cardiovascular disease. PI was positively correlated with BMI (P < 0.0001) and total cholesterol levels (P = 0.004). PI was negatively correlated with age (P < 0.0001), heart rate (P < 0.0001), and creatinine levels (P < 0.0001). Adjusted Cox regression analyses demonstrated that PI was associated with an increased hazard of cardiovascular death (hazard ratio 0.84; 95% CI; range 0.72-0.99). In addition, compared with patients with a high PI (> 3.7%), those with a low PI (≤ 2.0%) had a significantly increased risk of cardiovascular death. This low PI group had a hazard ratio of 3.49 (95% CI 1.73-7.82). The PI is a valuable predictor for cardiovascular death in a clinical setting.

Japanese Red Cross Osaka Hospital

Japanese Red Cross Osaka Hospital

P1649Prognostic significance of serum cholinesterase in patients with acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry

Abstract Background Comorbidities strongly influence the prognosis in heart failure with preserved ejection fraction (HFpEF). Malnutrition is one of the most important comorbidities among heart failure patients. Serum cholinesterase (CHE), one of the markers of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. In addition, we previously reported prognostic significance of CHE from a single center registry data of acute decompensated heart failure (ADHF). The aim of this study is to conduct external validation of the prognostic role of CHE using multi-center HFpEF registry. Methods and results Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals in Osaka recorded clinical, echocardiographic, and outcome data of patients with ADHF and preserved ejection fraction. Between June 2016 and January 2018, 381 patients were enrolled and we excluded patients without sufficient laboratory data and in-hospital death. Finally, we analyzed 204 patients with survival discharge. Laboratory data including CHE and echocardiography were obtained just before discharge. The endpoint of this study is the composite of all-cause death and worsening heart failure re-admission (cardiac event). During a follow up period of 0.92±0.37 years, 49 patients had cardiac event. CHE was significantly lower in patients with than without cardiac event (183±67 vs 223±71 U/L, p&lt;0.0001). At multivariate Cox analysis, CHE (p=0.0020) was significantly associated with cardiac event, independently of NT-pro BNP after adjustment of age, sex, eGFR and hemoglobin. ROC curve analysis showed that AUC of CHE for the prediction of cardiac event was 0.706 (95% CI 0.638–0.768). Kaplan-Meier analysis showed that patients with low CHE (&lt;211U/L defined by median) had a significantly greater risk of cardiac event (35% vs 13% p=0.0002). Figure 1 Conclusion Serum cholinesterase level is the useful prognostic marker for the prediction of cardiac event in patients with ADHF with preserved ejection fraction. Acknowledgement/Funding Roche diagnostics, FUJIFILM Toyama Chemical

Effects of an advance care planning educational programme intervention on the end-of-life care attitudes of multidisciplinary practitioners at an acute hospital: A pre- and post-study

Background: Advance care planning is a crucial end-of-life care practice. However, an advance care planning educational programme for practitioners in an acute care setting has not yet been established. Consequently, we examined the effects of an advance care planning educational programme in an acute hospital in the hope of achieving increased awareness of end-of-life care. Design: A mixed-methods, pre- and post-design was employed to evaluate the change in attitudes of practitioners post-programme. The intervention programme was conducted thrice over 3 months in 90-min sessions. Setting/participants: This study included 85 participants in the baseline assessment working at B acute hospital in Osaka. Results: Participants’ scores on the ‘Positive attitude for end-of-life care’ subscale on the short version of the Frommelt Attitude Toward Care of Dying scale significantly increased after the 6-month intervention. A ‘Positive attitude for end-of-life-care’ implies that participants would not be afraid to practice end-of-life care. Further, participants’ scores on the ‘Death relief’ subscale of the Death Attitude Inventory also significantly increased. The term ‘Death relief’ means that death helps in ending suffering. It means participants are not afraid of death. Qualitative results implied that participants believed advance care planning implementation and communicating with patients and patients’ families were critical. Conclusions: Six months post-intervention, participants displayed sustained positive attitudes towards end-of-life care. These results suggest that the present programme was effective at improving practitioners’ attitudes towards patients’ end-of-life care.

Single versus multiple cervical dilation by osmotic dilator before induction of labor for second‐trimester abortion

In this study, we aimed to investigate whether there was a significant prognostic difference between single and multiple cervical dilations when inducing second-trimester abortion. We conducted a retrospective review of 238 pregnant women who underwent termination of pregnancy at 12-21 weeks of gestation at Osaka University Hospital in Osaka, Japan, between January 2010 and May 2018. Termination of pregnancy was performed by vaginal administration of 1 mg gemeprost every 3 h for up to five doses per day after uterine cervical dilation using lamicel. The women were categorized into two groups: 191 women had a delivery time of <24 h, whereas 47 had delivery times >24 h. Contrasting the groups, there were significant differences with regard to numbers of primiparas (88 [46.1%] and 32 [68.1%], respectively) and lamicel exchanges ± SD (1.9 ± 0.67 for <24 h and 2.4 ± 0.87 for >24 h, respectively). Additionally, we compared the prognosis of primiparas that received just a single lamicel with that of primiparas that had ≥2 exchanged, but no significant differences were noted in the number of patients with a delivery time of >24 h and the number of used gemeprost. Primipara is a risk factor for delayed delivery time of induced abortion. However, increasing the number of exchanged lamicel did not significantly reduce the delivery time; therefore, it should be performed as minimally as possible.

Work environment, governance and service quality in Japanese healthcare

Objectives: This paper explores the contribution of governance to work environment and service quality in Japanese healthcare. Research design: Data for this project was collected by giving questionnaires to the staff at eight cooperative hospitals across Japan in 2016 and compared with similar data from the staff at two public hospitals in Osaka in 2017. The staff sample from these 10 hospitals was a total of 6,859, with a response rate of 72.1%. Findings: Based on the “demand, control, support” model of Karasek & Theorell, we found that more staff control over their daily work life resulted in greater staff satisfaction and promoted better service quality. Governance proved to be an intervening factor of significant importance and this paper considered three differentiated models for governing the provision of healthcare in Japan. They were distinguished in terms of the autonomy given to the staff in their everyday work life as well as patient inclusion in hospital discussions and decision-making. Implications: Greater staff autonomy and more patient inclusion can have a positive effect both on work environment and service quality. Governance models can, therefore, contribute to or detract from goals of achieving greater staff autonomy, better service quality and more patient inclusion. Contribution: This study tapped into Japan’s unique healthcare system, with two user-owned co-operative healthcare providers that manage nearly 200 hospitals with almost 50,000 beds, in order to explore work environment, governance and service quality. Questionnaires given to nearly 7,000 hospital employees allowed us to explore in depth the contribution of governance to work environment and service quality in Japanese healthcare. These results can serve as a best practice for other healthcare providers in Japan and elsewhere.

Patients With Obesity Exhibit a Plateau Pattern of the Right Ventricular Waveform.

BackgroundVentricular waveforms are characterized by a dip-and-plateau pattern during diastole owing to an abrupt termination of ventricular filling because of pericardial constraint under conditions such as constrictive pericarditis (CP). However, constrictive hemodynamics is not specifically caused by CP. Therefore, this study aimed to evaluate whether patients with obesity exhibited constrictive hemodynamics.MethodsOverall, 60 consecutive Japanese patients (mean age, 69.5 years; 45% women) who underwent right heart catheterization at the Japan Community Healthcare Organization Osaka Hospital from July 2016 to September 2018 were examined. Two-dimensional echocardiography was used to measure the epicardial adipose tissue (EAT) in the standard parasternal long-axis view during end-diastole. Because patients who underwent open-heart surgery were highly likely to have CP, they were excluded.ResultsAmong the 60 patients, 11 (18%) exhibited a plateau pattern of the right ventricular waveform and had a mean EAT value of 4.2 mm, which was significantly higher than that of patients without such a pattern (2.1 mm, P < 0.001). Similarly, the mean body mass index (BMI) values were significantly higher in patients with a plateau pattern than in those without it (27.2 vs. 21.8 kg/m2, P < 0.001). EAT was significantly correlated with the BMI (r = 0.72, P < 0.001). In patients with a plateau pattern, the triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C) levels were significantly higher (TG: 150 vs. 100 mg/dL, LDL-C: 121 vs. 95 mg/dL, P < 0.05) and the left atrial diameter (52.8 vs. 44.7 mm, P < 0.01) and left atrial volume index (58.7 vs. 47.6 mL/m2, P < 0.05) were significantly greater than those in the patients without it. The EAT was also significantly correlated with the TG level (r = 0.37, P < 0.01).ConclusionsObese patients may present with constrictive hemodynamics, suggesting left ventricular diastolic dysfunction. EAT was significantly correlated with metabolic syndrome components, namely obesity and TG levels.

Gastric Xanthoma Is a Predictive Marker for Early Gastric Cancer Detected after Helicobacter pylori Eradication.

Objective The detection of early gastric cancer (GC) after Helicobacter pylori eradication is expected to increase in Japan. However, the predictive markers for early GC detected after H. pylori eradication have not been extensively studied. We conducted a retrospective, single-center observational study to investigate the predictive markers for early GC detected after H. pylori eradiation. Methods A total of 421 patients underwent endoscopic submucosal dissection for early GC at NTT West Osaka Hospital between June 2006 and August 2017. Data from patients with GC (Group C; n=70) and without GC (Group NC; n=114) after H. pylori eradication were analyzed. Results The proportion of men was significantly higher in Group C than in Group NC (92.9% vs. 65.8%; p<0.0001). Complications with other malignant diseases were more prevalent in Group C than in Group NC. A significantly greater proportion of patients had gastric xanthoma (GX) in Group C than in Group NC (64.3% vs. 14.9%; p<0.0001). Regarding scores for endoscopic findings related to the risk of GC, the atrophy score, intestinal metaplasia score and total score were significantly higher in Group C than in Group NC. A multivariate logistic regression analysis identified male sex, atrophy (open type), the presence of intestinal metaplasia and GX as independent predictors for early GC detected after H. pylori eradication. An atrophy-matched control analysis also identified GX as an independent predictor. Conclusion GX is a novel predictive marker for early GC detected after H. pylori eradication.

Retrospective analysis of liraglutide and basal insulin combination therapy in Japanese type 2 diabetes patients: The association between remaining β-cell function and the achievement of the glycated hemoglobin target 1 year after initiation.

Aims/IntroductionThe glucose‐lowering effects of the glucagon‐like peptide‐1 receptor agonist, liraglutide, have been shown to rely on remaining β‐cell function. However, the possible associations of remaining β‐cell function with the glucose‐lowering effects of liraglutide in combination with basal insulin remain unknown and warrant investigation.Materials and MethodsThis was a single‐center, retrospective, observational study carried out in a private hospital in Osaka, Japan. Type 2 diabetes patients who received a prescription change from insulin therapy, both multiple‐dose insulin and basal insulin‐supported oral therapy, to liraglutide and basal insulin combination and continued the therapy for 54 weeks without additional oral antidiabetic drugs or bolus insulin were retrospectively analyzed.ResultsAmong the 72 participants who received a prescription change from multiple‐dose insulin and basal insulin‐supported oral therapy to liraglutide and basal insulin combination, 57 continued the therapy for 54 weeks. Of those who continued the therapy without receiving additional oral antidiabetic drugs or bolus insulin, seven participants achieved glycated hemoglobin < 7.0% at 54 weeks, but 30 participants did not. The participants who achieved glycated hemoglobin < 7.0% at 54 weeks had a significantly higher C‐peptide immunoreactivity index, a β‐cell function‐related index frequently used in Japanese clinical settings. The receiver operating curve analysis showed that the C‐peptide immunoreactivity index cut‐off value for the achievement of glycated hemoglobin <7.0% at 54 weeks is 1.103.ConclusionsThe current findings show that the glucose‐lowering effects of liraglutide rely on remaining β‐cell function, even when used with basal insulin; and suggest that liraglutide and basal insulin combination might require additional bolus insulin to fully compensate insulin insufficiency in individuals with reduced β‐cell function.

Peritoneal Seeding after Gastric Perforation during Endoscopic Submucosal Dissection for Gastric Cancer

Background/Aims: Since the risk of cancer cells seeding the peritoneum after perforation during endoscopic submucosal dissection (ESD) is unclear, we retrospectively examined peritoneal relapse after gastric perforation during ESD for gastric cancer at a single institution. Methods: Of 876 patients who underwent ESD for early gastric cancer between January 2002 and December 2015, 22 patients (2.5%) experienced gastric perforation during ESD at the Osaka National Hospital in Osaka, Japan. Clinical data from these 22 patients were reviewed for information on pathology, clinical course, and evidence of peritoneal dissemination. Results: Patients were followed for a median of 55 (range 2–108) months. Two patients had peritoneal seeding following perforation during ESD. Multivariate analysis to explore the influence of clinical factors on the peritoneal seeding revealed that an intra-abdominal fluid collection on the CT imaging just after ESD, tumor location at the upper lesion of stomach, and pathologically marginal invasion were independently associated with an incidence of peritoneal relapse. Conclusion: Although rare, we should recognize the possibility of cancer cells seeding the peritoneum after perforation during gastric ESD.

O31-3 - Trends in Heart Failure Hospitalization in Cardiology Department of a University Hospital in Osaka between 1990 to 2015

Japan is presently aging more rapidly than anywhere else in the world. With rapidly aging population, the disease structure in cardiology greatly changes and prevalence of heart failure (HF) is increasing. To clarify this, we retrospectively examined characters of patients admitted to the cardiology department in our hospital every 5 years between1990 and 2015. Elderly patients were defined as aged >65 years and very elderly as aged >75 years. The age of hospitalized patients increased as over time. HF admission increased, in particular, the number of very elderly patients increased rapidly. Since 2010, more than half of very elderly patients admitted due to HF. In conclusion, HF admission has increased rapidly in aging society and it becomes center of medical care in current cardiology.

Health-Related Quality of Life and Sleep Disorders in Patients With a Urostomy: Is There a Relationship?

The purpose of this study was to evaluate the relationship between health-related quality of life (HRQOL) and sleep disorders in persons living with a urostomy. A cross-sectional descriptive study. Eighty-six adults with a urostomy who were cared for in a stoma outpatient clinic of a hospital in Osaka, Japan, for at least 1 month before data collection, and who were attending support group meetings comprised the sample. The majority of participants (n= 68; 79.1%) were diagnosed with bladder cancer; the median time since ostomy surgery was 3.7 years. Participants were queried about demographic and pertinent clinical data; they also completed 2 instruments that measured HRQOL and sleep quality. All data were collected via interview. HRQOL was assessed using a Japanese language version of the World Health Organization Quality of Life (WHOQOL). Sleep quality was evaluated using a Japanese language version of the Pittsburgh Sleep Quality Index (PSQI-J). Demographic and clinical data were collected via a questionnaire designed for this study. WHOQOL scores among persons living with a urostomy were significantly (P < .001) lower than scores among the general population in Japan. Forty-six participants (53.5%) had scores that were higher than 5.5, the cut-off point on the PSQI-J indicating reduced sleep quality. Scores on the PSQI-J were significantly negatively associated with the cumulative scores for WHOQOL scores (standardized partial regression coefficient -0.504, P < .001) even after adjustment based on all other variables. Study findings suggest that persons with a urostomy have lower HRQOL and sleep quality than adults in the general population.

Gastric xanthoma is a predictive marker for metachronous and synchronous gastric cancer.

AIMTo investigate predictive markers for metachronous and synchronous gastric cancer (GC), which can develop after endoscopic submucosal dissection (ESD).METHODSA total of 352 patients underwent ESD for early GC at NTT West Osaka Hospital between June 2006 and February 2016. Exclusion criteria were as follows: Remnant stomach, unknown Helicobacter pylori status, and endoscopic observation of the whole stomach outside our hospital. We analyzed data from 192 patients comprising 109 patients with solitary GC (Group A) and 83 with metachronous and synchronous GC (Group B). We retrospectively investigated the clinicopathological and endoscopic characteristics, and endoscopic risk score as predictive markers for GC.RESULTSThe median age of Group B [72 years (interquartile range 63-78)] was significantly higher than that of Group A [66 years (interquartile range 61-74), respectively, P = 0.0009]. The prevalence of intestinal metaplasia in Group B tended to be higher than that in Group A (57.8% vs 45.0%, P = 0.08). The prevalence of gastric xanthoma (GX) in Group B was significantly higher than that in Group A (54.2% vs 32.1%, P = 0.003). The atrophy score in Group B was significantly higher than that in Group A (P = 0.005). Multivariate analysis revealed that higher age and the presence of GX were independently related to metachronous and synchronous GC [OR = 1.04 (1.01-1.08), P = 0.02; and OR = 2.11 (1.14-3.99), P = 0.02, respectively].CONCLUSIONThe presence of GX is a useful predictive marker for metachronous and synchronous GC.

Professor Nambu, string theory, and the moonshine phenomenon

I first recall the last occasion of meeting the late Professor Yoichiro Nambu in a hospital in Osaka. I then present a brief introduction to the moonshine phenomenon in string theory which is under recent investigations.

Travel-related illness at a tertiary care hospital in Osaka, Japan.

We analyzed the travel-related health problems in persons returning to Japan from overseas. Data were extracted retrospectively for all patients visiting the infectious diseases department of Osaka City General Hospital, Osaka, Japan, between July 2012 and September 2013. There were 209 sick returning travelers during the period of the study. The median age of the subjects was 34.3 years, and the subjects consisted of 133 tourists (63.6%), 39 business travelers (18.7%), 17 expatriates (8.1%), 14 volunteer workers (6.7%), and four persons who visited friends and relatives (1.9%). The most visited destinations were Asia (n=162, 77.5%), including East Asia (n=26, 12.4%), Southeast Asia (n=116, 55.5%), South Asia (n=25, 12.0%), Central Asia (n=3, 1.4%), and Africa (n=30, 14.3%). The most commonly diagnosed diseases were gastrointestinal tract infection (n=81, 38.8%), dengue fever (n=26, 12.4%), and animal bites (n=26, 12.4%). Twenty-nine patients (13.8%) were hospitalized, mainly for dengue fever and gastrointestinal tract infection.

Eruptive Xanthoma with Acute Pancreatitis in a Patient with Hypertriglyceridemia and Diabetes.

Dear Editor: A 41-year-old Japanese man presented in October 2013 with a 2-week history of pruritic, erythematous papules. He had diabetes mellitus, hyperlipidemia, and hypertriglyceridemia, but had stopped treatment 5 years prior to this visit. He also suffered from acute pancreatitis, and was admitted to the Department of Medicine, Japan Community Healthcare Organization Osaka Hospital, 1 day prior. Topical steroid ointment prescribed during a previous visit to another clinic was ineffective for the treatment of the papules. At the time of consultation, he presented with multiple, approximately 5-mm, pruritic, yellowish, erythematous papules on the trunk and extensor surfaces of the extremities (Fig. 1A). Dermoscopic examination of the papules clearly revealed granular yellowish characteristics (Fig. 1B). The laboratory findings (normal values are in parentheses) were: white blood cell count, 13.3×103 (4.0×103~8.5×103)/µl; neutrophils, 83.5% (38%~58%); alkaline phosphatase, 369 (115~359) U/L; C reactive protein, 5.91 (<0.3) mg/dl; hemoglobin A1c, 9.2% (4.6%~6.2%); amylase, 340 (40~130) IU/L; lipase, 960 (11~53) U/L; triglyceride, 6,784 (30~150) mg/dl; total cholesterol, 803 (130/219) mg/dl; high density lipoprotein cholesterol, 12 (42~74) mg/dl; low density lipoprotein cholesterol, 23 (70~140) mg/dl; remnant-like lipoprotein particle cholesterol, 84.4 (<7.5) mg/dl; apolipoprotein (Apo) A-I, 89 (119~155) mg/dl; Apo A-II, 12.6 (25.9~35.7) mg/dl; Apo B, 135 (73~109) mg/dl; Apo E, 11.0 (2.7~4.3) mg/dl; Apo C-II, 16.5 (1.8~4.6) mg/dl; Apo C-III, 28.3 (5.8~10.0) mg/dl. A skin biopsy sample obtained from papules on the waist revealed foamy cells that infiltrated the dermis. At higher magnification, foamy cells and extracellular lipids were present (Fig. 2). Therefore, we diagnosed the patient as having eruptive xanthoma with type V hyperlipoproteinemia according to Fredrickson's classification of hyperlipoproteinemias. We treated the acute pancreatitis with fasting, nafamostat mesilate, and ulinastatin, and the hypercholesterolemia with bezafibrate. The acute pancreatitis improved 16 days after admission. Serum triglyceride and total cholesterol values decreased to within normal range 1.5 months after the initiation of treatment. The eruptive xanthoma lesions rapidly resolved as the hyperlipidemia improved. Fig. 1 (A) Clinical appearance and (B) dermoscopic appearance of multiple yellowish erythematous papules on the patient's back in October 2013. Fig. 2 Skin biopsy from the erythematous papules present on the patient's waist. (A) At lower magnification, numerous pale areas containing foamy cells infiltrate the dermis, especially the upper dermis and perivascular areas (H&E, ×40). (B) ... Hyperlipidemia is divided into six subgroups. Cutaneous xanthomatous lesions can occur in all six types of hyperlipidemia1. Cutaneous xanthomas can be divided into subgroups, including eruptive xanthomas, tuberous xanthomas, tendon xanthomas, xanthelasmata, and plane xanthomas2. Eruptive xanthomas can be associated with hypertriglyceridemia (Type I, IV, or V hypercholesterolemia), particularly when diabetes is poorly controlled2,3. Eruptive xanthomas contain more triglycerides and fewer cholesteryl esters than other types of xanthomas, and lipids present in xanthomas are derived from circulating plasma lipoproteins. Triglyceride is mobilized more rapidly than cholesterol, so resolving eruptive xanthomas are rich in cholesterol4. Hypertriglyceridemia also increases the risk of acute pancreatitis, and the risk of eruptive xanthoma and pancreatitis increases when the serum triglyceride concentration reaches the thousands5. Eruptive xanthomas manifested in this patient 2 weeks before his visit, followed by acute pancreatitis. Dermatologists should carefully consider the possibility of acute pancreatitis with hypertriglyceridemia in eruptive xanthoma patients.