In obstructive sleep apnea syndrome (OSAS), an underlying disease of secondary hypertension, repeated episodes of asphyxia due to obstructive sleep apnea (OSA), followed by arousal, lead to various cardiovascular consequences. Using a canine model of OSAS, it was found that a single load of OSA caused an abrupt increase in blood pressure (BP) (Apnea Surge in seconds), while multiple OSA episodes occurring nightly for 1-3 months led to a sustained elevation of BP during both nighttime and daytime. Epidemiological studies on 24-hour ambulatory BP measurements revealed that some hypertensive patients experienced elevated BP in the early morning (Morning Surge), which could be intensified by OSAS. The resonance of Apnea Surge in seconds and Morning Surge increases the risk of organ damage, triggers the cardiovascular events, and adversely affects the prognosis of hypertensive patients with OSAS. For ameliorating these risks, OSA should be treated with positive airway pressure properly.

The year 2023 marked a significant change for Internal Medicine, as the number of submissions related to the novel coronavirus infection (COVID-19) declined significantly and interest shifted to other disease fields and research areas. Our journal published its first articles on artificial intelligence (AI) and machine learning (ML), and these articles have shown that AI may be useful for the early detection of potential cardiac diseases, while ML can be used to predict the risk of serious illness in patients hospitalized with COVID-19, providing new possibilities for diagnoses and treatment. In addition to touching on the above, the present article also highlights the status of submissions to the journal (including the number of submissions and acceptance rate) in 2023.

Objective The presence of a short white hair-like appearance in the lower esophagus has recently been noted during esophagogastroduodenoscopy (EGD) at our institution. Histological findings showed that this formation was a spiked protrusion of the esophageal papilla. The results regarding the prevalence of such lesions in individuals who underwent EGD examinations as part of medical checkup procedures are herein presented.

Methods The EGD results of 14,338 individuals (9,225 males, 5,113 females; mean age 54.0±9.8 years) were examined. The findings related to the presence of multiple lesions with a short white hair-like appearance in the lower esophagus of patients with reflux esophagitis, esophageal squamous papilloma, or gastric mucosal atrophy (GMA), as well as the hiatal hernia width, were investigated.

Results Endoscopic findings indicating short white hair-like appendages in the lower esophagus were noted in 167 patients, with a prevalence rate of 1.2%. A female sex, younger age, lower body mass index, lower percentages of habitual smoking and drinking, and the presence of esophageal squamous papilloma were characteristic features of cases with such findings. In addition, a significantly lower prevalence of reflux esophagitis and a smaller diaphragmatic hiatus size were observed. A multiple logistic regression analysis indicated that a female sex, absence of reflux esophagitis, presence of esophageal squamous papilloma, and a smaller diaphragmatic hiatus were factors significantly related to the presence of these short white hair-like appendages. An analysis of circumferential localization revealed the main location to be the left-posterior wall.

Conclusion This study is the first to report the prevalence of multiple short white hair-like appendages in the lower esophagus. The occurrence of such lesions is inversely associated with the presence of reflux esophagitis.

Objective Gastrointestinal (GI) disorders such as functional dyspepsia (FD), irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and inflammatory bowel disease (IBD) can exhibit overlapping GI symptoms, including abdominal pain and alterations in bowel habits. The symptoms of GI disorders are commonly considered to be triggered and exacerbated by fatty food intake. Therefore, this study aimed to compare the food preferences of patients with GI disorders.

Methods Forty food images (including fatty and light foods) and 20 animal images were selected to evaluate food preferences. The preference score was assessed using a visual analog scale ranging from 1 to 100. GI symptoms were evaluated using the GI Symptom Rating Scale (GSRS), and correlations between the GSRS and preference scores were investigated.

Results Overall, 22 healthy controls and 23, 29, 27, and 20 patients with FD, IBS, GERD, and IBD, respectively, were enrolled. The preference score for all foods in patients with FD was significantly lower than that in healthy controls and those with IBS, GERD, and IBD (52.9 vs. 66.5 vs. 68.5 vs. 69.1 vs. 70.7, p<0.01). The score of fatty foods was lower in patients with FD than in healthy controls and those with IBS, GERD, and IBD (43.8 vs. 72.3 vs. 77.5 vs. 77.4 vs. 80.7, p<0.01), whereas that of light foods and animal images was not different among the groups. No significant correlation was found between the preference score and symptom severity.

Conclusion Patients with FD had a negative preference for foods, particularly fatty foods, independent of the severity of GI symptoms.

Objective Patients undergoing maintenance dialysis are at a higher risk of morbidity and mortality due to severe coronavirus disease 2019 (COVID-19) than the general population. However, longitudinal data regarding this subpopulation of patients are lacking. We therefore examined the prognosis of patients with COVID-19 undergoing maintenance dialysis between 2020 and 2023. In addition, we explored the factors correlated with COVID-19 severity, focusing on the transition thereof throughout the observational period.

Methods The primary outcome was the progression to severe or fatal COVID-19. We evaluated the correlation between the primary outcome and baseline demographic and clinical characteristics of patients. Patients undergoing maintenance dialysis who were hospitalized for mild-to-moderate COVID-19 between February 2020 and April 2023 were enrolled at four institutions in Kanagawa, Japan.

Results Of the 173 patients, 7 (4.0%) developed severe COVID-19, and 12 (6.9%) died. The severe/death cohort was significantly older, with a higher percentage of unvaccinated patients than the non-severe cohort (58.2% and 25.0%, respectively; p=0.016). Thymus and activation-regulated chemokine levels on admission were lower in the severe/death cohort than in the non-severe cohort, albeit not to a statistically significant degree (148±84 mg/dL and 342±657 pg/mL, respectively; p=0.082). A multivariate logistic regression analysis revealed that the odds ratio for severe morbidity or death was 0.23 (95% confidence interval: 0.07-0.75) for vaccinated patients.

Conclusion In patients undergoing maintenance dialysis, the severity rate of COVID-19 is approximately 10%. Vaccination was correlated with a reduced risk of severe COVID-19.

Atopic dermatitis is common in children and often treated with topical corticosteroids (TCs). A boy in his late teens who had been using TCs for atopic dermatitis was diagnosed with liver damage during a health checkup. A medical examination revealed severe steatotic liver disease and elevated liver enzyme levels despite the absence of typical symptoms such as central obesity. After discontinuation of TCs, an improvement in liver enzyme levels was observed, leading to the diagnosis of drug-induced steatohepatitis. This case underscores the potential liver risks associated with prolonged TC use in children, highlighting the need for parental education.

In November 2019, a 76-year-old woman was diagnosed with limited cutaneous scleroderma caused by Raynaud's phenomenon and skin hardening on the periphery of the extremities. In October 2022, blood tests and abdominal ultrasonography revealed liver dysfunction and multiple liver masses, respectively. In November 2022, a percutaneous liver mass biopsy revealed peliosis hepatitis, so the patient was referred to Kindai University Hospital, and signs of liver failure were observed. Considering her age, the patient was ineligible for liver transplantation, and she died in September 2023. Peliosis hepatis complicated by scleroderma has not been previously reported, so we report this as a valuable case.

Cytokeratin (CK) is a specific marker of adenocarcinoma. However, cases of CK7-positive esophageal squamous cell carcinoma (ESCC) have only rarely been reported. We herein report a case of unresectable CK7-positive ESCC with aggressive liver metastasis following nivolumab treatment initiation. Nivolumab treatment was discontinued after one course because of complications. Notably, the liver metastases exhibited accelerated growth. Immunostaining of the necropsy specimens revealed diffuse positivity for forkhead box protein A1 (FOXA1)/CK7, thus indicating a potent poor immune response. The potential correlation between CK7 expression and the immune checkpoint inhibitor response may offer valuable insights into the development of effective therapeutic strategies.

In Japan, public health improvements have lessened parasitic infections, but increased global travel has introduced new disease risks. We report the case a Japanese man who had previously resided in Vietnam, who experienced appendicitis and the presence of segments in his stool. Gastrografin led to the expulsion of Taenia saginata, as confirmed by scolex identification. Remarkably, the appendicitis symptoms subsided after deworming. This case underscores the importance of considering cestode infections in the differential diagnosis of appendicitis, particularly for patients with relevant travel histories, and highlights the evolving challenges in global health and the significance of acquiring detailed patient histories.

A 34-year-old transgender woman presented with ventricular tachycardia and was diagnosed with takotsubo cardiomyopathy. Further evaluation revealed an underlying diagnosis of multiple sclerosis (MS) with brainstem lesions that may have triggered takotsubo cardiomyopathy. In this report, we also systematically reviewed published cases of takotsubo cardiomyopathy and MS and found that basal type takotsubo cardiomyopathy was the most common, and most patients presented with brainstem involvement of MS. An awareness of these associations by physicians, along with multidisciplinary collaboration, may facilitate the early diagnosis and improve the prognosis of these patients.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a complication caused by antithyroid drugs, particularly propylthiouracil (PTU). Most patients experience organ failure due to the affects of the treatment regimen. We herein report the case of an 89-year-old woman whose severe AAV induced by PTU resulted in various instances of organ failure that eventually led to death after 9 years of PTU therapy. During autopsy, we identified five types of organ failure. As AAV is a potentially fatal disease, the development of various vasculitis symptoms during PTU therapy should therefore be carefully monitored.

A 78-year-old male was admitted to the hospital with acute renal failure and generalized erythema after starting dapagliflozin 10 mg/day for chronic kidney disease (CKD). A skin biopsy revealed superficial perivascular dermatitis with eosinophils. A renal biopsy revealed lymphocytic and eosinophilic infiltration of the interstitium, and focal tubulitis. The patient was diagnosed with a dapagliflozin-induced drug reaction with eosinophilia and systemic symptoms (DRESS), followed by acute interstitial nephritis (AIN), and prednisolone therapy was therefore initiated. The patient's renal function improved, and erythema disappeared. To our knowledge, this is the first report of DRESS caused by dapagliflozin, and the patient was successfully treated with prednisolone.

Immune checkpoint inhibitors can cause a range of immune-related adverse events, including myositis, Takotsubo cardiomyopathy, and myasthenia gravis. We herein report a rare case of a 78-year-old man with concurrent durvalumab-induced myositis, Takotsubo-like morphological changes caused by myocarditis, and myasthenia gravis. The patient initially required invasive ventilation and exhibited symptoms of myasthenia gravis after treatment with high-dose steroids. However, he subsequently achieved successful recovery after the administration of intravenous immunoglobulin, plasmapheresis, and high-dose steroids. We advocate vigilant neurological monitoring of patients with immune checkpoint inhibitor-induced myositis, including the assessment of ptosis and other relevant signs, so that prompt treatment can be initiated at the time of emergence or progression of immune checkpoint inhibitor-induced myasthenia gravis.

A 72-year-old man was admitted to our hospital with a complaint of breathlessness. Computed tomography revealed a tumor with intense early enhancement and pleural effusion. Although the pleural effusion was not bloody, the tumor showed a hypervascular area on angiography. Left thyrocervical artery embolization was performed to prevent bleeding during the operation. After embolization, chest radiography revealed decreased pleural effusion. The tumor was resected and pathologically diagnosed as a mediastinal cavernous hemangioma. To our knowledge, mediastinal hemangiomas with pleural effusion are extremely rare; thus, this is the first report of reduced pleural effusion in mediastinal hemangiomas after artery embolization.

Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM)-associated interstitial lung disease (ILD) can sometimes be complicated by pneumomediastinum, although tension pneumomediastinum is extremely rare. We herein report a case of anti-MDA5 antibody-positive DM-ILD that worsened subcutaneous and mediastinal emphysema during treatment. Hypotension and worsening respiratory failure were observed on day 20 of treatment. Mediastinal drainage under video-assisted thoracoscopic surgery promptly improved the patient's circulatory and respiratory status. Tension pneumomediastinum is a rare complication; however, it is a serious condition that may lead to hypotension or cardiac arrest and requires a prompt diagnosis and treatment.

Nodal T-follicular helper cell lymphoma (nTFHL), a hematologic neoplasm originating from T-follicular helper (TFH) cells, occasionally presents with pulmonary radiographic abnormalities, without neoplastic cellular infiltration. However, the precise mechanisms underlying non-neoplastic pulmonary opacities in patients with nTFHL remain unclear. Previous reports have shown that TFH cell abnormalities are associated with collagen disease and interstitial pneumonia with autoimmune features (IPAF). We herein report a patient with nTFHL accompanied by interstitial pneumonia diagnosed via lung and lymph node biopsies. These findings suggest the need to rule out nTFHL before diagnosing IPAF.

Assisted reproductive technology is a viable option for pregnant women with chronic myeloid leukemia. We herein report the case of a patient who underwent successful fertility treatment with frozen embryo preservation at 36 years of age, followed by embryo transfer at 39 years of age, thus resulting in pregnancy and delivery after a third discontinuation of tyrosine kinase inhibitors (TKIs). Despite the difficulty of long-term TKI withdrawal, the patient's strong desire for a baby led to a successful pregnancy and delivery with no apparent deformities or abnormalities. Thus, our case highlights the importance of collaboration between reproductive medicine physicians and hematologists.

A 44-year-old woman with a subacute onset of an altered mental status, urinary retention, and fluctuating blood pressure was initially diagnosed with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, meeting the criteria of Graus et al. Cardiac arrest occurred, which required pacemaker placement. She subsequently showed profound flaccid limb paralysis, with magnetic resonance imaging demonstrating focal necrotic lesions localized in the anterior horn of the longitudinal segments of the spinal cord and in the pontine tegmentum. Enteroviruses or autoimmune encephalitis-associated autoantibodies were not detected. We herein report a case of acute flaccid myelitis with profound psychiatric symptoms and dysautonomia, resembling NMDAR encephalitis.

A 68-year-old woman was admitted to our hospital because of a rapid progression of renal dysfunction with positive myeloperoxidase antineutrophil cytoplasmic antibody and was diagnosed with rapidly progressive glomerulonephritis associated with microscopic polyangiitis (MPA). Severe right rectus sheath hematoma (RSH) bleeding from the inferior epigastric artery developed after starting hemodialysis, which required 4 transarterial embolizations due to recurrent bleeding. After additional treatment with methylprednisolone pulse therapy and rituximab, no rebleeding occurred. Although the giant hematoma reached the pelvis, it shrank spontaneously without any intervention. Nontraumatic RSH should therefore be considered when treating patients with multiple risk factors.