Morphological features of the posterior oblique ligament of the ulnar collateral ligament of the elbow joint.

PURPOSE: The purpose of this basic research study was to clarify the morphological characteristics of the posterior oblique fibers (POL) of the ulnar collateral ligament using a large number of specimens. METHODS: This study examined 50 arms from 25 Japanese cadavers. Type classification was performed by focusing on the positional relationship between POL morphology and the joint capsule. The morphological features measured were fiber bundle length, width, and thickness. RESULTS: The POL was classified as follows: Type I, the POL's anterior and posterior edges are located on the surface of the joint capsule and can be separated as a single fiber bundle; Type II-a, the POL anterior edge can be separated, but the posterior edge cannot be separated; Type II-b, the POL posterior edge can be separated, but the anterior edge cannot be separated; and Type III, the POL cannot be separated from the joint capsule. Type I was seen in 23 elbows (46%), Type II-a in 6 elbows (12%), Type II-b in 7 elbows (14%), and Type III in 14 elbows (28%). CONCLUSION: The results of this study suggested that the POL could be classified into an independent type and an unclear type, and the presence of the unclear type was one of the factors that caused morphological variation.

Morphological features of the deep component of the posterior inferior tibiofibular ligament.

PURPOSE: The deep component of the posterior inferior tibiofibular ligament (PITFL) was classified by type in this large-scale cadaveric study to provide basic information that will help elucidate the mechanisms underlying ankle joint posterior impingement syndrome. METHODS: This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In classification, absence of an independent fiber of the deep component of the PITFL were classified as Type I, an independent fiber of the deep component of the PITFL was classified as Type II-a, an independent fiber of the deep component of the PITFL with bundles of fibers connected to the posterior intermalleolar ligament (PIML) was classified as Type II-b, and an independent fiber of the deep component of PITFL with a band shape connected to the PIML was classified as Type III. RESULTS: A deep component of the PITFL was present in all specimens. An independent fiber of the deep component of the PITFL was present in 37 legs (37%), connecting to the deep component of the PITFL and PIML in 26 (70.3%). Several types of deep component of the PITFL were identified: Type I in 63 legs (63%); Type II-a in 11 (11%); Type IIb in 12 (12%); and Type III in 14 (14%). No significant differences were seen between the right and left legs. Type I male were significantly more than Type I female (p < 0.05). Type III female were significantly more than Type III male (p < 0.05). CONCLUSIONS: Strong relationships exist between the PITFL and PIML.

Morphological features of the cervical ligament.

PURPOSE: The purpose of this study was to clarify the morphological characteristics of the cervical ligament (CL). METHODS: This study examined 80 legs from 40 Japanese cadavers. The CL was classified by the number of fiber bundles. The morphological features measured were fiber bundle length, width, thickness, and angle with the sagittal plane. RESULTS: The CL was classified as follows: Type I, the CL is a single fiber; Type II, the CL consists of a superficial fiber and an inferior fiber; and Type III, the CL consists of a superficial fiber, intermediate fiber, and inferior fiber. Type I was seen in 15 feet, Type II in 57 feet, and Type III in 8 feet. In comparisons of morphological features within each type, significant differences were seen in fiber bundle length, width, and angle between superior fiber bundles and inferior fiber bundles of Type II and Type III. In comparison among types, the total fiber bundle width was significantly wider in Type II and Type III than in Type I, and the angle was significantly smaller in Type III than in Type I. CONCLUSION: The results of this study suggested that each type may have different sub-talar joint control functions.

Morphological features of the posterior intermalleolar ligament.

PURPOSE: In the present study, the posterior intermalleolar ligament (PIML) was classified by type using large-scale cadavers to provide basic information to help elucidate the mechanism of ankle joint posterior impingement syndrome. METHODS: This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In the classification method, an absent PIML was classified as Type I, a PIML with one fiber bundle (attachment to one place) was Type II, a PIML with two fiber bundles (attachment to two places) was Type III, and a PIML with three fiber bundles (attachment to three or more places) was Type IV. Furthermore, according to other adhering tissues, they were further subdivided and classified by type. RESULTS: There were various types of PIML: 19 (19%) Type I; 24 (24%) Type II; 23 (23%) Type III; and 34 (34%) Type IV. A PIML was present in 81 legs (81%). There were no significant differences between men and women and between left and right sides. CONCLUSIONS: The complex relationships of the PIML with the surrounding ligaments and tissues are considered to be among the factors that make interpretation of imaging findings difficult.

Morphological features of the bifurcated ligament.

INTRODUCTION: Damage to the bifurcate ligament is one of the most difficult injuries to diagnose from imaging techniques. A probable reason for this is that the morphological characteristics of this structure have yet to be sufficiently elucidated. We, therefore, endeavored to elucidate the morphological characteristics of the bifurcate ligament through a large-scale study involving numerous specimens. MATERIALS AND METHODS: This study included 100 feet from 52 formalin-fixed cadavers. The bifurcate ligament was classified into three types: presence of both calcaneonavicular ligament and calcaneocuboid ligament (Type I); absence of calcaneocuboid ligament (Type II); and absence of calcaneonavicular ligament (Type III). Morphological characteristics of the bifurcate ligament were determined by measuring fiber bundle length, width, and thickness at the center of each ligament. RESULTS: This classification resulted in 68 Type I feet (68%), 32 Type II feet (32%), and 0 Type III feet (0%). The calcaneonavicular ligament was 20.8 ± 2.9 mm long, 4.9 ± 1.2 mm wide, and 3.8 ± 1.1 mm thick. The calcaneocuboid ligament was approximately 10.5 ± 2.7 mm long, 4.7 ± 2.4 mm wide, and 1.5 ± 0.6 mm thick. The bifurcate ligament was located deep under the extensor hallucis brevis and extensor digitorum brevis muscles in all specimens. The calcaneal origin of the calcaneonavicular ligament was situated deep under the interosseous talocalcaneal ligament in all specimens. Two sides were identified in which the calcaneocuboid ligament was located deep under the dorsal calcaneocuboid ligament. CONCLUSION: Such variations and positional relationships were suggested to be factors complicating the diagnostic imaging of bifurcate ligament injuries. The present study results will likely form useful basic data for diagnostic imaging.

Excessive CD4+ T cells co-expressing interleukin-17 and interferon-γ in patients with Behçet's disease.

Excessive T helper type 1 (Th1) cell activity has been reported in Behçet's disease (BD). Recently, association of Th17 cells with certain autoimmune diseases was reported, and we thus investigated circulating Th17 cells in BD. CD4(+) CD45RO(-) (naive) T cells were cultured with Th0-, Th1-, Th2- and Th17-related cytokines and antibodies, and their mRNA was studied by real-time polymerase chain reaction (PCR). When naive CD4(+) T cells were cultured with Th1- and Th17-related cytokines, interferon (IFN)-γ mRNA and interleukin (IL)-17 mRNA were up-regulated, respectively, in BD patients. Naive CD4(+) T cells cultured in a Th17 cell-inducing condition expressed IL-23 receptor (IL-23R) mRNA excessively. IL-17 mRNA expression was induced only when naive CD4(+) T cells were cultured in the presence of IL-23. CD4(+) T cells cultured with Th17 cytokines expressed excessive RAR-related orphan receptor C (RORC) mRNA. Using intracellular cytokine staining, we found that CD45RO(+) (memory) CD4(+) T cells producing IL-17 and IFN-γ simultaneously were increased significantly. Memory CD4(+) T cells producing IFN-γ but not IL-17 decreased profoundly in BD patients. CD4(+) T cells producing IL-17 and IFN-γ simultaneously were found in BD skin lesions. Collectively, we found excessive CD4(+) T cells producing IL-17 and IFN-γ (Th1/Th17) cells in patients with BD, and possible involvement of IL-23/IL-23R pathway for the appearance of excessive Th1/Th17 cells.

Skewed TGFß/Smad signalling pathway in T cells in patients with Behçet's disease.

OBJECTIVES: Behçet's disease (BD) is a multi-systemic inflammatory disease, characterised by recurrent oral aphthosis, genital ulcers, skin lesions and uveitis. We have reported excessive Th1 cell activity in patients with BD. More recently, Th17 cells were suggested to associate with several autoimmune diseases. This study was designed to investigate the role of Th17 related cytokines and signalling molecules in patients with BD. METHODS: We examined mRNA expressions of Th1 and Th17 related cytokines and related signalling molecules in PBMC of 12 patients with BD and 14 normal controls (NC) using quantitative RT-PCR. We studied expressions of the Th17 related cytokines in other four BD patients' skin lesions by immunofluorescence. RESULTS: Major Th17 related cytokines were not detected in unstimulated PBMC in patients with BD. After stimulation, mRNA expressions of TGFß receptor type 1, IL-12 receptor ß2 and suppressor of cytokine signalling protein (SOCS) 1 on PBMC were significantly enhanced in patients with BD, as compared with NC (p<0.05). mRNA expression of RORC, a key transcription factor for Th17 cell differentiation, was comparable between BD and NC. CD4+ T cells infiltrating into BD skin lesion expressed TGFß1 much more than those infiltrating into non-Behçet's disease erythema nodosum. CONCLUSIONS: These findings suggest that TGFß/Smad signalling pathway of T cells is overactive in patients with BD.

A case of anti-laminin gamma-1 (p200) pemphigoid with bullous lesions on the lips, hands and feet showing antibodies to desmoglein 1.

An 87-years-old-man presented with bullous and erosive lesions exclusively on the lips, hands and feet. Histopathological and direct immunofluorescence studies suggested the diagnosis of bullous pemphigoid, but the serum anti-BP180 antibodies were negative. Strangely, anti-desmoglein 1 antibodies were positive, although no pemphigus-like features were found. Indirect immunofluorescence showed IgG reactivity with dermal side of 1 M NaCl-split skin. Immunoblotting showed positive reactivity with the 200 kDa laminin gamma-1 but not with type VII collagen. After the administration of prednisolone 20 mg/day, bullous lesions cleared within 2 weeks.

Morphological characteristics of the Lisfranc ligament.

BACKGROUND: This study aimed to clarify the morphological characteristics of the Lisfranc ligament and the cuneiform 1-metatarsal 2&3 plantar ligament (CMPL). METHODS: Forty legs from 20 cadavers were examined. Classification proceeded according to the number of fiber bundles in the Lisfranc ligament and the CMPL. Morphological features measured were fiber bundle length, width, thickness, and angle. RESULTS: In Type I-a, the Lisfranc ligament and the CMPL were a single fiber bundle; in Type I-b, the Lisfranc ligament was a single fiber bundle, and the CMPL was two fiber bundles; in Type II-a, the Lisfranc ligament was a two fiber bundle, and the CMPL was a single fiber bundle; in Type II-b, the Lisfranc ligament and the CMPL were two fiber bundles; in Type III-a, the Lisfranc ligament was three fiber bundles, and the CMPL was a single fiber bundle; in Type III-b, the Lisfranc ligament was three fiber bundles, and the CMPL was two fiber bundles; in Type IV, the Lisfranc ligament and the CMPL could not be separated. Type I-a was seen in 37.5%, Type I-b in 10%, Type II-a in 30%, Type II-b in 7.5%, Type III-a in 7.5%, Type III-b in 2.5%, and Type IV in 5%. The Lisfranc ligament was significantly larger than the CMPL in total fiber bundle width, total fiber bundle thickness, and total fiber bundle angle. CONCLUSION: The Lisfranc ligament had up to 3 fiber bundles and the CMPL had one or two fiber bundles; classifications were four types and two subgroups.

Association analysis between canine behavioural traits and genetic polymorphisms in the Shiba Inu breed.

The relationships between behavioural trait data and the genotype of 15 polymorphisms in eight neurotransmitter-related genes were analysed in 77 dogs of the Shiba Inu breed, an indigenous Japanese dog. The data were obtained from a 26-item questionnaire on the dog's behaviour, distributed to the dog's owners, through veterinary hospitals and the Shiba Inu breed magazine. A factor analysis of the questionnaire items extracted eight factors accounting for 66.8% of the variance. An association analysis between these factors and genetic polymorphisms indicated that the polymorphism of c.471T>C in the solute carrier family 1 (neuronal/epithelial high-affinity glutamate transporter) member 2 (SLC1A2) gene was significantly associated with Factor 1, referred to as 'aggression to strangers'. This association remained stable in separate analyses of data from surveys obtained from the hospitals and those obtained from the magazine. The results suggest that the c.471T>C polymorphism is associated with some types of aggressive behaviour in the Shiba Inu. Further studies using other dog breeds are necessary to extend these findings to dogs in general.

Effect of joint position on the electromyographic activity of the semitendinosus muscle.

The semitendinosus (ST) muscle has a tendinous intersection within the muscle belly that separates the ST muscle into distinct proximal and distal compartments. Thus far, no study has compared the electromyographic (EMG) activities between the proximal and distal compartments of the human ST muscle. This study aimed to investigate the intramuscular EMG activity patterns of the proximal and distal compartments of the ST muscle by altering the hip and knee joint positions. The study population comprised eight healthy male volunteers. They performed ramp isometric knee flexion tasks form the relaxed state to the maximal voluntary contraction (MVC) state with (1) the hip and knee at 90 degrees and 0 degrees, respectively (90-0 position), (2) both the hip and knee at 00 (0-0 position), and (3) the hip and knee at 0 degrees and 90 degrees, respectively (0-90 position). Fine-wire electrodes were inserted into the proximal and distal compartments of the ST muscle and the individual EMG activities were recorded. In the 90-0 position, the EMG activity of the distal compartment was higher than that of the proximal compartment at 60%, 80%, and 90% MVC. Moreover, in the 0-90 position, the EMG activity of the proximal compartment was higher than that of the distal compartment at 60% MVC. These results indicated that the lengthened or shortened muscle conditions induced regional differences in the EMG activity patterns, while the two compartments showed equivalent activity when the muscle length was moderate.

Morphological features of the inferior fascicle of the anterior inferior tibiofibular ligament.

In this study, the inferior fascicle of the anterior inferior tibiofibular ligament (AITFL) was classified to provide basic information to help elucidate the mechanism of ankle joint anterolateral impingement, and the morphological features of each type were compared for the purpose of clarification. This investigation examined 100 feet from 52 cadavers. The AITFL was classified into four types according to the presence or absence of the inferior fascicle and the positional relationship between the AITFL and the inferior fascicle of the AITFL. The morphological features of the AITFL that were measured included the fibre bundle length, fibre bundle width, fibre bundle angle, and the distance between the joint levels. A distinct, independent inferior fascicle of the AITFL was identified in 15 feet (15%). There were no significant differences in the morphological features based on differences in the AITFL classification. Therefore, these findings suggest that the presence or absence of the inferior fascicle and the difference in the positional relationship between the AITFL and the inferior fascicle of the AITFL are less likely to be involved in impingement during ankle dorsiflexion.

Nitric oxide synthesis in the lung. Regulation by oxygen through a kinetic mechanism.

In this study, we show that oxygen regulates nitric oxide (NO) levels through effects on NO synthase (NOS) enzyme kinetics. Initially, NO synthesis in the static lung was measured in bronchiolar gases during an expiratory breath-hold in normal individuals. NO accumulated exponentially to a plateau, indicating balance between NO production and consumption in the lung. Detection of NO2-, NO3-, and S-nitrosothiols in lung epithelial lining fluids confirmed NO consumption by chemical reactions in the lung. Interestingly, alveolar gas NO (estimated from bronchiolar gases at end-expiration) was near zero, suggesting NO in exhaled gases is not derived from circulatory/systemic sources. Dynamic NO levels during tidal breathing in different airway regions (mouth, trachea, bronchus, and bronchiole) were similar. However, in individuals breathing varying levels of inspired oxygen, dynamic NO levels were notably dependent on O2 concentration in the hypoxic range (KmO2 190 microM). Purified NOS type II enzyme activity in vitro was similarly dependent on molecular oxygen levels (KmO2 135 microM), revealing a means by which oxygen concentration affects NO levels in vivo. Based upon these results, we propose that NOS II is a mediator of the vascular response to oxygen in the lung, because its KmO2 allows generation of NO in proportion to the inspired oxygen concentration throughout the physiologic range.

Kinesthetic illusory feeling induced by a finger movement movie effects on corticomotor excitability.

The present study aimed to clarify whether a kinesthetic illusion arises in our experimental condition (visual stimulus) and whether corticomotor excitability changes in parallel with the kinesthetic illusion. The visual stimulus was a movie in which someone else's limb was being moved. The computer screen showing the movie was installed at an appropriate portion of the subject's forearm, so that the performer's hand appeared as if it were the subject's hand (illusion). The experience of kinesthetic illusion under this condition was verified by interview using a visual analog scale. Healthy male subjects participated in this experiment. Transcranial magnetic stimulation was applied to induce motor-evoked potential (MEP) from the first dorsal interosseous and abductor digiti minimi muscle. Each subject was instructed to watch the same computer display shown as in the illusion, with his own stationary hand in full view (non-illusion) and to watch a display of non-biological movement (moving text) (sham) as the control conditions. The present results showed significant facilitation of MEP under the illusion compared with the control conditions for the index finger abducting in the movie, although not for adducting. MEP in the abductor digiti minimi showed no change during either abduction or adduction of the little finger. The present study demonstrated that an illusion of self-motion can be created by a video of a moving abstract index finger, and inputs to the corticomotor pathways during the self-motion illusion facilitated the corticomotor excitability. The excitatory effect of the illusion depended on the movement direction of the index finger.

Diversity in the fatty-acid conformation and chain packing of cis-unsaturated lipids.

Recent X-ray diffraction and Fourier transform IR spectroscopic studies have unveiled a great diversity in the molecular conformation and chain packing of lipid molecules containing cis-unsaturated fatty-acid chains. Specifically, a dramatic diversity in the olefinic conformation, subcell packing and chain-chain interactions has been clearly revealed by crystal structures of principal cis-monounsaturated fatty acids. The structural diversity is most manifest in oleic acid crystals. These findings were applied to analyses of the complicated structural transformation of diacylglycerols and triacylglycerols containing oleic acid and saturated acid moieties, in which the stabilization of the oleic acid causes the complexity of the transformation and mixing behavior. Although this knowledge has been obtained in the crystalline state, one may assume that the structural diversity of these unsaturated molecules plays a similar role in the lipids of biomembranes, lipoproteins and lipid deposits in which aliphatic chain packing is a critical problem, since most lipid domains can undergo liquid to solid or solid to liquid alterations.

Increased arginase II and decreased NO synthesis in endothelial cells of patients with pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH), a fatal disease of unknown etiology characterized by impaired regulation of pulmonary hemodynamics and vascular growth, is associated with low levels of pulmonary nitric oxide (NO). Based upon its critical role in mediating vasodilation and cell growth, decrease of NO has been implicated in the pathogenesis of PAH. We evaluated mechanisms for low NO and pulmonary hypertension, including NO synthases (NOS) and factors regulating NOS activity, i.e. the substrate arginine, arginase expression and activity, and endogenous inhibitors of NOS in patients with PAH and healthy controls. PAH lungs had normal NOS I-III expression, but substrate arginine levels were inversely related to pulmonary artery pressures. Activity of arginase, an enzyme that regulates NO biosynthesis through effects on arginine, was higher in PAH serum than in controls, with high-level arginase expression localized by immunostaining to pulmonary endothelial cells. Further, pulmonary artery endothelial cells derived from PAH lung had higher arginase II expression and produced lower NO than control cells in vitro. Thus, substrate availability affects NOS activity and vasodilation, implicating arginase II and alterations in arginine metabolic pathways in the pathophysiology of PAH.

Novel point mutations in the steroid sulfatase gene in patients with X-linked ichthyosis: transfection analysis using the mutated genes.

X-linked ichthyosis is caused by steroid sulfatase deficiency which results from abnormalities in its coding gene. The majority of X-linked ichthyosis patients ( approximately 90%) have complete or partial deletions of the steroid sulfatase gene. In this study, we examined the mutations of the steroid sulfatase gene in two unrelated X-linked ichthyosis patients without complete deletion of the gene. Polymerase chain reaction-single-strand conformation polymorphism and direct sequencing analyses showed that each patient has a different single base pair substitution within exon 8 encoding the C-terminal half of the steroid sulfatase polypeptide. Both mutations resulted in the transversion of functional amino acids: a G-->C substitution at nucleotide 1344, causing a predicted change of a glycine to an arginine, and a C-->T substitution at nucleotide 1371, causing a change from a glutamine to a stop codon. In vitro steroid sulfatase cDNA expression using site-directed mutagenesis revealed that these mutations are in fact pathogenic and reflect the levels of steroid sulfatase enzyme activities in each of the X-linked ichthyosis patients.

Induction of transcription factor AP-2 by inflammatory cytokines in human keratinocytes.

Activator protein-2 is an important transcription factor for the activation of a number of genes. Here we report the induction of activator protein-2 in response to inflammatory cytokines such as interleukin-6 in keratinocytes. Immunoblotting and semiquantitative reverse transcriptase-polymerase chain reaction assays using normal human keratinocytes revealed that interleukin-6 caused a time- and concentration-dependent induction of activator protein-2 mRNA and protein. The increase of activator protein-2 mRNA was detected at 30 min after stimulation and that of activator protein-2 protein was at 2 h. Their levels were lower than the control levels at 24 h. The interleukin-6-dependent induction of activator protein-2 mRNA was completely blocked by adding actinomycin D, whereas it was approximately 50% affected by cycloheximide. Co-incubation with neutralizing antibodies against various inflammatory cytokines resulted in inhibition of the interleukin-6-dependent activator protein-2 induction at varying degrees, indicating an involvement of various cytokines in the activator protein-2 induction. The activator protein-2 induction was observed in keratinocytes derived from lesional skins with psoriasis or squamous cell carcinoma, and the high levels of activator protein-2 were histochemically detected in these lesions. Furthermore, a gel mobility shift assay using the nuclear extracts from interleukin-6-treated cells showed that interleukin-6 induced the functional activator protein-2 protein for the gene activation. These findings suggest a possible regulation mechanism of activator protein-2 through a complex cytokine system, which is conceivably the initial reaction leading to skin inflammation, and resultant keratinocyte growth and carcinogenesis.

Analysis of immunological responses in psoriatic lesions: (1) immunopathological studies on psoriatic lesions.

In order to understand immunological responses in psoriatic lesions, immunofluorescent findings have been compared in early psoriatic lesions and fully developed plaque lesions. IgG and IgA were detected as the main antibodies in the horny layer by immunohistology. The IgA at the site of leukocyte accumulation in the horny layer seemed to be associated with secretory component (S-component) and joining chian. Regarding complement, the alternate pathway might be related to the immune reaction as the initial response, because deposits of C3, properdin and glycine rich beta-glycoprotein were found more frequently than C1q-deposit in the both lesions. In the dermis S-component was also detected at the dermal papillae adjacent to the dermoepidermal (D-E) junction of the lesions and no deposit of S-component was observed in uninvolved skin of psoriatic patients. This, however, is not a specific pattern in psoriatic lesions since deposits of S-component were found at the dermal papillae and D-E junction in other dermatoses. These findings might suggest that the immunological response was initiated by secretory IgA in horny layer, which was composed of dimeric IgA and S-component at the D-E junction and which passed easily through the epidermal cells.

High prevalence rate of Helicobacter pylori resistance to clarithromycin during long-term multiple antibiotic therapy for chronic respiratory disease caused by non-tuberculous mycobacteria.

BACKGROUND: Helicobacter pylori resistance to clarithromycin, probably due to the frequent use of this antibiotic for the treatment of other diseases, is the greatest obstacle against its eradication. AIM: To clarify the prevalence of clarithromycin-resistant H. pylori in patients with non-tuberculous mycobacterial lung disease receiving multiple antibiotic treatment, including clarithromycin. METHODS: We enrolled 88 patients with non-tuberculous mycobacterial lung disease; 29 underwent upper gastrointestinal endoscopy for the diagnosis of H. pylori infection prior to treatment, and 60 underwent it during treatment. The diagnosis of H. pylori infection was confirmed by histological examination, urease test and microaerobic bacterial culture. The minimum inhibitory concentration of clarithromycin was determined and the DNA was analysed for each of the isolated H. pylori strains. RESULTS: Patients during the treatment had a high prevalence rate of clarithromycin-resistant H. pylori (100%). Analysis of DNA of the clarithromycin-resistant H. pylori isolates revealed point mutations at A2142G or A2143G. Moreover, a linear correlation was found between the total cumulative dose of clarithromycin and the minimum inhibitory concentration. CONCLUSION: All patients with non-tuberculous mycobacterial lung disease being treated long-term with multiple antibiotics, including clarithromycin, harboured clarithromycin-resistant H. pylori in the stomach. Therefore, eradication of H. pylori before commencement of long-term therapy including clarithromycin should be recommended.