Objective Extracorporeal shock wave lithotripsy (ESWL) has been used to treat pancreatolithiasis in patients with chronic pancreatitis (CP), but the high recurrence rate remains challenging. We therefore evaluated the association between body composition parameters and the prediction of retreatment after ESWL.

Methods This study retrospectively evaluated 42 patients with CP who had been treated with ESWL between 2008 and 2019 in a single center. Body composition parameters were measured on pretreatment computed tomography images. Patients who underwent repeat ESWL were classified as the retreatment group.

Results There were 13 (31.0%) and 29 (69.0%) patients in the retreatment and non-retreatment groups, respectively. The visceral-to-subcutaneous adipose tissue area ratio (VSR) of the retreatment group was significantly lower than that of the non-retreatment group (p=0.016). When divided by the median VSR, 10 of the 20 patients with a VSR of <0.85 underwent retreatment, whereas 3 of the 22 patients with a VSR of ≥0.85 underwent retreatment (p=0.019). According to a multivariate analysis, the VSR (p=0.010) and age (p=0.037) were independent factors associated with retreatment after ESWL.

Conclusion This study showed that the VSR can predict the retreatment of patients with CP after ESWL.

Objective The coronavirus disease (COVID-19) pandemic has altered the delivery of medical care. The present study evaluated the impact of COVID-19 on the outcomes of unresectable pancreatic cancer (PC) patients who received end-of-life care.

Methods We retrospectively compared the management of PC patients during the COVID-19 pandemic (from April 2020 to March 2021) to the preceding year, which was unaffected by the pandemic (from April 2019 to March 2020), based on a prospectively maintained institutional database.

Results A total of 178 patients were included in the COVID-19-exposed group and 201 patients were included in the COVID-19-unexposed group. The median overall survival was similar between the groups (exposed vs. unexposed: 12.6 vs. 11.9 months, p=0.174). Treatment regimens and relative dose intensities and the progression-free survival of GnP (gemcitabine in combination with nab-paclitaxel) and mFOLFIRINOX as first- and second-line chemotherapy did not differ significantly between the two groups. Only 9.0% of patients died at home in the COVID-19-unexposed group, compared to 32.0% in the COVID-19-exposed group (p<0.001). A multivariate analysis revealed that death during the COVID-19 exposed period was independently associated with home death (odds ratio: 4.536, 95% confidence interval: 2.527-8.140, p<0.001).

Conclusions While the COVID-19 pandemic did not seem to influence chemotherapeutic treatment for PC patients at our institution, it had a large impact on end-of-life care. These findings may promote discussion about end-of-life care in Japan.

Objective In patients with coronavirus disease 2019 (COVID-19), understanding the timeline of oxygen demand and severe respiratory failure, such as intensive care unit (ICU) admission, may clarify the therapeutic window when home-care treatment is possible and help determine the timing of treatment in hospitalized patients to improve the respiratory status. We examined the timeline of respiratory status in hospitalized patients with moderate-to-severe COVID-19 in terms of oxygen demand and ICU admission.

Methods We retrospectively assessed all patients with COVID-19 who were admitted to our hospital between February 2020 and February 2021 and required supplemental oxygen. This study included 66 patients who were transferred to the ICU (ICU patients) and 144 patients who were not transferred to the ICU (non-ICU patients).

Results In the total cohort, the median duration from symptom onset to the need for supplemental oxygen was 8 [interquartile range (IQR) 6-10] days. This duration was significantly shorter in ICU patients than in non-ICU patients [8 (IQR 6-9) vs. 9 (IQR 6-10) days, p=0.02]. The median duration from symptom onset to ICU admission was 9 (IQR 8-11) days in severely ill patients. The median duration from the initiation of supplemental oxygen to ICU admission was 1.0 (IQR 1-2.75) days. Only 2 of 66 patients (3.0%) were admitted to the ICU six days or later after the initiation of supplemental oxygen.

Conclusion Physicians should carefully monitor each patient's condition after eight days from symptom onset. New therapies and their early administration are needed to reduce the frequency of respiratory failure in COVID-19 patients.

Objective Just before the Tokyo 2020 Olympic and Paralympic Games in Japan, the number of people infected with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), started to increase at an unprecedented rate. This study investigated the effectiveness of vaccines in large-scale sporting events under difficult circumstances, such as during adherence to a bubble system and confinement inside the Olympic/Paralympic Village.

Methods In collaboration with medical clinics inside and outside the Village, a prospective cohort study was conducted among overseas participants using the results of polymerase chain reaction (PCR) tests for SARS-CoV-2 upon leaving Japan.

Results A total of 12,072 foreign participants were enrolled, 13 (0.11%) of whom had a positive PCR test result. None of these cases were broadcasters or members of the press, were tested outside the Olympic Village, or had a history of COVID-19 infection. The effectiveness of full vaccination and vaccination at least once (≥14 days ago) was 74% [95% confidence interval (CI): 6-93%] and 81% (95% CI: 30-95%), respectively. Three breakthrough infections with the Delta variant were observed in 6,485 fully vaccinated participants (0.05%). The positivity rate was 0.09% among adherents to the bubble system and 0.28% among non-adherents, but this difference was not significant.

Conclusion These findings indicate that even huge sporting events such as the Olympic and Paralympic Games can proceed while pandemics are ongoing in the host country by combining countermeasures such as vaccination, frequent testing, social distancing, and adherence to a bubble system.

Objective Quantification of patient encounters during internal medicine residency training is challenging. At present, there are no established strategies for evaluating the whole inpatient experience in Japan. We hypothesized that the Diagnosis Procedure Combination (DPC) database, which is widely used in Japan, might be a useful tool for such an evaluation.

Methods We analyzed DPC-based patient encounters of five senior residents with different types of training. One of the diseases on receipt computation data, including the four main diseases and at most eight comorbidities, was matched with each category in the Online system for Standardized Log of Evaluation and Registration of specialty training system (J-OSLER), and the match ratios were assessed. The accumulation of each disease classified into J-OSLER categories was also assessed. Monthly extra working hours and total patient-days per resident were evaluated using a Pearson correlation analysis.

Results Two residents with two-year rotations in the general internal medicine department showed high numbers of patient encounters and the highest matching ratio with J-OSLER (approximately 60% with 4 major diseases, 91% with all diseases). There was a moderately positive correlation between the total patient-days and extra working hours in these residents, but no such correlation was noted in the rate of monthly patient encounters and extra working hours among residents as a whole.

Conclusion The DPC-based quantification of patient encounters during residency training appears effective in evaluating the coverage of the current J-OSLER list. Owing to its wide availability and generalization, this matching method may be useful as a universal tool for assessing internal medicine programs.

The histopathological findings of immune checkpoint inhibitor (ICI)-induced pancreatitis have rarely been reported. A 56-year-old man with squamous cell carcinoma of the lung with bone metastasis was being treated with pembrolizumab, an anti-programmed cell death protein-1 antibody. After 13 doses, he was referred to our department due to pancreatitis. Despite characteristic symptoms of acute pancreatitis, imaging findings were similar to those of autoimmune pancreatitis. However, a histological examination showed neutrophil-based inflammatory cell infiltration and acinar-ductal metaplasia. Immunostaining showed CD8-positive T lymphocyte infiltration. This case revealed the characteristic histopathology of pembrolizumab-induced pancreatitis, which was previously poorly understood.

Ebstein's anomaly is an uncommon congenital disorder affecting the tricuspid valve. We herein report a 38-year-old woman who experienced consciousness and sensory disturbance during treatment for heart failure caused by Ebstein's anomaly. Urgent magnetic resonance imaging and cerebral angiography demonstrated acute cerebral infarction and internal carotid artery obstruction with the development of collateral arteries. We diagnosed her with multiple cerebral infarctions due to moyamoya disease. Ebstein's anomaly concomitant with moyamoya disease is extremely rare. However, we should consider the possibility of this rare but important concurrence when treating patients with heart failure due to Ebstein's anomaly to avoid excessive diuresis and vasodilation and irreversible brain injury.

Intermittent left main coronary artery ostium obstruction (