Digital health, which encompasses digital medicine and therapy, integrates advanced technologies across healthcare. Central to this transformation is 'digitization,' which converts continuous analog data into a discrete digital form. However, this process is challenging. First, digitization inherently has the potential to introduce information loss, thereby diminishing the richness and complexity of data. Second, "digit bias," a cognitive distortion, emerges in the interpretation phase, where individuals' perceptions of and reactions to digital data are intrinsically skewed. There exist two major cognitive biases during digitization process: "digit preferences," where healthcare providers prioritize specific numbers, and "left digit bias" where continuous variables are disproportionately estimated by focusing on the leftmost digit. Although information loss and cognitive biases can cause significant distortions in healthcare, the effects of this "digitization" process have not been adequately quantified, and the accumulation of further evidence in this field is anticipated.

Objective To evaluate the influence of sample collection time during esophagogastroduodenoscopy (EGD) on the accuracy of a newly approved point-of-care test (POCT)-based polymerase chain reaction kit for detecting Helicobacter pylori and clarithromycin susceptibility in gastric wash fluid.

Methods Intragastric fluid was collected at three time points: Collection Time 1 (start of EGD), Collection Time 2 (during EGD), and Collection Time 3 (after indigo carmine spraying). POCT-based quantitative polymerase chain reaction (qPCR) targeting 23S rRNA domain V (2142/2143) was used to quantify H. pylori DNA in the collected fluid at all three time points and compared with qPCR targeting 16S rRNA.

Patients Fifty patients with suspected H. pylori infection were consecutively enrolled in this study over a three-month period and underwent EGD.

Results In 9 out of 50 EGD cases that were H. pylori-positive, no significant differences in H. pylori DNA content, quantified using POCT-based qPCR targeting 23S rRNA, were observed between the three collection times: 1 vs. 2, p=0.81; 2 vs. 3, p=0.59; 1 vs. 3. Collection Time 2 had the strongest inverse correlation with the urea breath test (r=-0.80, p=0.01) and was the only time-point at which POCT-based qPCR could detect H. pylori in case 15.

Conclusion This study suggests that the optimal collection timing for the H. pylori detection POCT kit (within 60 min) using intragastric fluid (with no biopsy) may be during EGD (Collection Time 2). However, our study had a limited sample size, so the findings must be verified through large-scale, multicenter collaboration studies.

Objective Intravascular large B-cell lymphoma (IVLBCL) is a critical cause of fever of unknown origin (FUO). While a pathological analysis is essential for diagnosing IVLBCL, the indications for an invasive procedure may be ascertained using easy, non-invasive tests. The lymphocyte-to-monocyte ratio (LMR) can reportedly predict the diagnosis of malignant lymphoma in patients with lymphadenopathy; however, its clinical utility in predicting an IVLBCL diagnosis in patients with FUO remains to be elucidated.

Methods The medical records of 91 patients with FUO who underwent a skin biopsy for suspected IVLBCL between January 2010 and April 2023 were retrospectively reviewed.

Patients Seventeen and 60 patients with and without pathologically diagnosed IVLBCL, respectively, were included in the analysis. The laboratory data nearest to the timing of the skin biopsy were then compared between the groups.

Results Among the variables with an intragroup difference, a low white blood cell (WBC) count and LMR were predictors of an IVLBCL diagnosis after adjusting for covariates. A receiver operating characteristic analysis demonstrated that a WBC ≤7,200 and LMR ≤3.0 predicted the diagnosis with a sensitivity of 88.2% and 100%, and a specificity of 65.0% and 43.3%, respectively. In addition, the probability of IVLBCL increased to 71.4% in patients with both variables but was 0% in those with neither variable, indicating its potential utility in determining the need for an invasive procedure.

Conclusion The WBC count and LMR predicted an IVLBCL diagnosis in patients presenting with FUO.

Objective Switching from one anti-calcitonin gene-related peptide monoclonal antibody (CGRP mAb) to another can be beneficial for treating patients with migraine who do not respond well to the first CGRP mAb. However, detailed and long-term follow-up reports of both efficacy and safety remain insufficient. We conducted a case-series analysis of patients with migraine who switched from galcanezumab to erenumab, both belonging to the class of CGRP mAbs.

Methods We conducted a single-center retrospective real-world study. Patients with migraine who first received galcanezumab for ≥3 months and then switched to erenumab at Keio University Hospital were enrolled to investigate changes in monthly migraine days (MMD), response rate, and adverse effects (e.g., injection-site reactions). Additionally, we performed a narrative review of the literature on switching CGRP mAbs.

Results Among the nine patients enrolled, the 50% response rate for MMD was 33% at 3 months after switching. Two patients (22%) initially responded at the 3-month assessment, but later reverted to baseline MMD levels. Switching from galcanezumab to erenumab increased the frequency of constipation, which was typically managed using laxatives. Participants who experienced injection-site reactions tended to exhibit similar reactions regardless of the type of CGRP mAb used. Five patients (56%) demonstrated an improvement in satisfaction after erenumab initiation at least once. A literature review revealed that the characteristics of the cohorts varied among studies.

Conclusion Switching from galcanezumab to erenumab was effective in some patients, while it was associated with some tolerable side effects, and it improved patient satisfaction in approximately half of the patients, despite interindividual diversity in responses and fluctuating responses after switching, which warrants further investigation.

Objective Patients with hip fractures tend to have a poor prognosis. Although guideline-compliant practices are known to improve patient outcomes, there is a lack of evidence regarding the use of intervention to improve guideline adherence in hip fracture patients. The objective of our study was to evaluate guideline adherence by internists providing care to patients with hip fractures, using a protocol developed based on various guidelines.

Method Protocol-driven care for hip fracture patients by internists began in April 2018 at our hospital. After its initiation, orthopedic surgeons performed the surgery, and the internists provided all other medical care. A controlled interrupted time-series analysis was used to evaluate the effects of protocol-driven care on guideline adherence to compare our hospital with other hospitals, using data extracted from a nationwide Japanese inpatient database covering the period April 2014 to March 2023.

Results A total of 221,620 inpatients from 373 hospitals were included in the study. The initiation of protocol-driven care was associated with the guideline-recommended prescriptions: osteoporosis medication (incidence rate ratio (IRR): 8.09; 95% confidence interval (CI) 4.02-17.7), acetaminophen (IRR: 2.11; 95% CI 1.55-2.90), non-steroidal anti-inflammatory drugs (IRR: 0.16; 95% CI 0.11-0.24), and opioids (IRR: 5.96; 95% CI 3.14-12.2). However, there was no effect on the proportion of benzodiazepine prescriptions, surgery within 48 hours, deep venous thrombosis prophylaxis, or other perioperative outcomes, including medical fees.

Conclusion The initiation of protocol-driven care by internists resulted in improved adherence to osteoporosis medication prescriptions and postoperative analgesic use compared with orthopedic care. This approach can be used as an effective method of care for elderly patients undergoing surgery.

Objective Evidence-based medicine (EBM) competency is crucial for healthcare professionals; however, validated tools to assess EBM skills in Japanese are scarce. This study aimed to develop and validate a Japanese version of the Assessing Competency in EBM (ACE) tool.

Methods We translated the ACE tool into Japanese, following international standards, and distributed it online to 99 healthcare professionals and students. The participants completed demographic questions and the Japanese version of the ACE tool. A subset also completed the retest and Fresno test. Internal consistency was assessed using Cronbach's alpha, test-retest reliability using the intraclass correlation coefficient (ICC), and construct validity using a confirmatory factor analysis and correlation with the Fresno test.

Results The Japanese version of the ACE tool showed a low internal consistency (Cronbach's alpha =0.31, 95% CI: 0.09-0.49), but an acceptable test-retest reliability (ICC =0.64, 95% CI: 0.40-0.81). A confirmatory factor analysis provided moderate support for the structure of the tool (SRMR =0.092, RMSEA =0.048, CFI =0.852). The tool demonstrated a moderate correlation with the Fresno test (r =0.35). The median completion time was 847 s (IQR, 577-1,249 s).

Conclusion Although the Japanese version of the ACE tool showed some promising aspects, including a quick administration and partial validity, its low internal consistency suggests that refinement is needed before it can be confidently used in Japanese medical education settings. Future studies should focus on improving the tool's reliability, potentially through in-person administration, to develop a robust EBM assessment tool in the Japanese healthcare context.

A 64-year-old man with cirrhosis was diagnosed with unresectable hepatocellular carcinoma and treated with a combination of durvalumab and tremelimumab. The patient had no history of diabetes mellitus. Three weeks later, the patient developed general fatigue, dry mouth, and polyuria. A subsequent blood examination revealed a blood glucose level of 706 mg/dL and C-peptide level of 0.29 ng/mL, with an HbA1c of 6.4%. The patient was diagnosed with fulminant type 1 diabetes mellitus. Although fulminant type 1 diabetes mellitus is a rare immune-mediated adverse event, it requires prompt attention shortly after the initiation of these agents owing to its severe and emergent nature.

A 65-year-old man with hepatocellular carcinoma and lung metastasis was treated with a combination of atezolizumab and bevacizumab. Subsequently, the patient developed fever and new liver lesions, which were considered to indicate a pseudoprogression. Despite this, the treatment was continued. Three months later, computed tomography scans demonstrated that the new lesions had disappeared and both the primary tumor and metastases had shrunk. A partial response was achieved and maintained for two years. A histological examination revealed a predominance of CD8-positive lymphocytes and programmed death-ligand 1-positive tumor-associated macrophages, which may predict a positive response to this therapy. Pseudoprogression may therefore be a favorable prognostic factor in hepatocellular carcinoma.

Myeloid sarcoma is a rare extramedullary tumor of immature myeloid cells that is often associated with acute myeloid leukemia (AML). We herein report an 81-year-old man who presented with intestinal obstruction due to myeloid sarcoma of the small intestine. Diagnostic challenges were overcome using double-balloon enteroscopy and a biopsy, which confirmed the diagnosis of myeloid sarcoma. The patient subsequently developed AML but responded well to chemotherapy. This case underscores the importance of considering myeloid sarcoma in the differential diagnosis of small-bowel tumors. Highlighting the significance of a histological analysis, even in patients presenting with small bowel obstruction, the early diagnosis and treatment are crucial for improving outcomes, particularly in patients without a history of hematologic malignancies.

Treating patients with latent tuberculosis infection (LTBI) to prevent the development of tuberculosis is a fundamental treatment strategy in daily practice. Isoniazid (INH) therapy for 6-12 months is recommended. However, INH can also cause hepatotoxicity. This report describes the autopsy case of a 65-year-old Japanese man diagnosed with LTBI who died of acute liver failure caused by INH.

Mesalazine-induced pericarditis is rare, and most cases occur at the time of treatment initiation. A 30-year-old man with ulcerative colitis who had experienced remission for 2 years with mesalazine 2,000 mg/day subsequently experienced relapse. Therefore, the mesalazine dose was increased to 4,000 mg. Thereafter, hematochezia improved, but anterior chest pain developed. Chest radiography revealed marked cardiac dilation (cardiothoracic ratio, 63%) and echocardiography revealed pericardial effusion. Adverse events associated with mesalazine should be carefully monitored, not only at the time of treatment initiation but also after dose escalation.

Whether or not pancreaticobiliary maljunction (PBM) is a risk factor for pancreatic cancer (PC) is unclear. We present a case of metachronous PC with PBM diagnosed after cholecystectomy for gallbladder cancer, in which follow-up imaging was possible until PC onset. A 63-year-old man who had been diagnosed with gallbladder cancer and had undergone cholecystectomy 5 years earlier developed pancreatitis. Pancreatography revealed PBM, and pancreatic duct brush cytology revealed adenocarcinoma. On reviewing the follow-up images, pancreatic morphological abnormalities, which had not been observed before cholecystectomy, were found to have gradually progressed, suggesting that biliopancreatic reflux led to pancreatic carcinogenesis.

Aortic intimal sarcoma is a rare disease with no established treatment and a poor prognosis. A 70-year-old man who underwent surgery for a mass shadow extending from the ascending aorta to the left common carotid artery on contrast-enhanced computed tomography was diagnosed with intimal sarcoma and underwent postoperative radiotherapy (66 Gy/33 Fr). Three brain metastases were identified after 1.5 months. No recurrence or enlargement was noted for four months following gamma knife radiosurgery and chemotherapy. To our knowledge, this is the first report of gamma knife radiosurgery delaying the progression of aortic intimal sarcoma.

As the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors has become widespread, euglycemic diabetic ketoacidosis (EDKA), a rare but notable complication associated with SGLT2 inhibitor use, is gaining attention, although the underlying mechanisms of SGLT2 inhibitor-associated EDKA remain unclear. This report describes the case of a 77-year-old male with type 2 diabetes mellitus on an SGLT2 inhibitor who developed EDKA just after undergoing percutaneous coronary intervention following acute myocardial infarction, with only one day of fasting, despite sufficient insulin secretion. Our case report provides valuable insights into the mechanism and management of SGLT2 inhibitor-associated EDKA in urgent clinical settings.

A 17-year-old Japanese boy was admitted to our hospital with intermittent claudication. He belonged to a weightlifting team at a high school. He had occasionally dropped lightweight lifting weights on his right foot. Arteriography of the right anterior and posterior tibial arteries revealed a 4-cm total occlusion in the right dorsalis pedis artery (DPA). Intravascular ultrasonography revealed intimal thickening and thrombus formation He was diagnosed with thrombus occlusion of the right DPA due to intimal artery damage caused by lightweight weightlifting. DPA thrombosis may occur in young athletes who do not have atherosclerosis or vasculitis.

There are no clear strategies for non-insulin-dependent slowly progressive type 1 diabetes mellitus (SPIDDM). We herein report a 25-year-old man with SPIDDM in whom appropriate diet therapy and exercise improved the initial insulin secretion without medication. After 12 months, his body weight decreased by 5.4 kg, and his muscle mass increased from 0.77 to 0.81 kg/body weight. Glycated hemoglobin levels were reduced from 6.4% to 5.7%. HOMA-IR decreased from 1.70 to 0.77; in particular, the insulinogenic index improved from 0.04 to 0.13. These improvements were maintained over five years with continuous lifestyle interventions. Patients with non-insulin-dependent SPIDDM may recover and retain their insulin secretion through lifestyle interventions.

In hemodialysis-related portal systemic encephalopathy (HRPSE), transient negative pressure in the inferior vena cava (IVC) during dialysis increases the blood flow through a portal-systemic shunt, leading to encephalopathy. We report the case of a 74-year-old man with a gastrorenal shunt who developed HRPSE for the first time following venous occlusion due to thrombosis around a right femoral tunneled-cuffed hemodialysis catheter. Before the thrombosis dissolved, ammonia levels increased after dialysis. Conversely, after the thrombosis was dissolved, the ammonia levels decreased after dialysis. We hypothesized that venous stasis in the right lower limb due to thrombosis intensified the negative pressure in the IVC during dialysis, triggering HRPSE.

A 50-year-old man presented to our hospital with a fever, edema, and a rash. The clinical diagnosis was renal dysfunction, nephrotic syndrome, and syphilis. The patient was treated with benzylpenicillin, and his symptoms improved. A renal biopsy revealed membranous nephropathy (MN). Recently, neuron-derived neurotrophic factor (NDNF) was reported to be an antigen corresponding to syphilis-associated MN. In the present patient, immunofluorescence staining and immunoelectron microscopy revealed granular NDNF-positive findings within subepithelial deposits, suggesting the presence of NDNF-IgG immune complexes. Although the mechanism by which NDNF serves as a target antigen remains unclear, NDNF was found to colocalize within subepithelial immune complexes in syphilis-associated MN.

We encountered a family with hereditary renal failure, renal medullary cysts, pancreatic hypoplasia, hypomagnesemia, liver enzyme abnormalities, and diabetes mellitus (DM). We identified a novel heterozygous variant of HNF1B (NM_000458.4:c.791dup, p.L264Ffs*30) using whole-exome sequencing of genomic DNA samples from this family. This variant is located in the DNA-binding domain of the HNF1B protein and produces a truncated protein with a de novo sequence, suggesting that this variant changes HNF1B binding to genomic DNA or causes nonsense-mediated mRNA decay. Based on the phenotypes and identified gene variants, this family suffers from autosomal dominant tubulointerstitial kidney disease caused by this HNF1B variant.

Durvalumab plus platinum-based chemotherapy is the first-line treatment for extensive-stage small-cell lung cancer. Immune checkpoint inhibitors (durvalumab) can cause immune-related adverse events (irAEs). We herein report the first case of fatal sepsis with anti-interleukin-6 autoantibody production following durvalumab administration. A 62-year-old woman with extensive-stage small-cell lung cancer received carboplatin-etoposide plus durvalumab chemotherapy. Serum C-reactive protein (CRP) levels decreased below the detection sensitivity post-treatment. She developed severe sepsis during maintenance durvalumab therapy; however, her serum CRP level did not increase. The serum tested positive for anti-interleukin-6 autoantibodies, which can cause CRP-less infections. Anti-interleukin-6 autoantibody production and subsequent sepsis without serum CRP elevation are possible irAEs.

An 83-year-old man presented with persistent fever after intravesical BCG therapy for bladder cancer. Chest computed tomography (CT) and bronchoscopy revealed diffuse ground-glass opacities with multiple micronodules and lymphocyte-predominant bronchoalveolar lavage fluid with a high CD4/CD8 ratio, respectively. Therefore, corticotherapy for interstitial pneumonia was initiated. Anti-fast staining of the respiratory specimens was negative; however, anti-tuberculosis treatment was added based on CT findings suggesting disseminated BCG infection. Fifty days post-admission, Mycobacterium bovis BCG was identified in the initial sputum cultures. Concomitant interstitial pneumonia and BCG infection should be considered in patients with abnormal chest imaging following intravesical BCG therapy.

A 69-year-old man with systemic sclerosis and interstitial pneumonia presented with an abnormal shadow in the right upper lung lobe. A thoracoscopic needle biopsy was performed on the right upper lobe lesion, and Mycobacterium malmoense was identified by 16S rRNA and rpoB gene sequencing. Surgical treatment was performed to obtain a radical cure, and lung squamous cell carcinoma and M. malmoense infection were detected in the resected specimen. We herein report the first case of the successful treatment of a patient with pulmonary M. malmoense infection and concomitant lung squamous cell carcinoma.

A 51-year-old man presented to the emergency department with rapidly progressive dyspnea that developed while climbing Mount Fuji. He had climbed Mount Fuji twice without experiencing similar symptoms. On arrival, his oxygen saturation was 91% on 10 L/min of oxygen with a non-rebreather mask. Chest imaging revealed scattered bilateral infiltrating shadows. He was diagnosed with high-altitude pulmonary edema (HAPE) and treated with high-dose corticosteroids, calcium-channel blockers, antibiotics, and oxygen via a high-flow nasal cannula. The patient responded to treatment and was discharged on day 7. Climbers should be aware of the risk of HAPE when climbing Mount Fuji.

A 70-year-old woman was admitted to our hospital with dyspnea. Atypical cells with multilobated nuclei were observed in the pleural effusion. Diffuse large B-cell lymphoma (DLBCL) was diagnosed based on a cell block analysis. A chromosomal analysis of lymphoma cells revealed t(14;18)(q32;q21) and t(3;22)(q27;q11). The patient's disease was refractory to chemotherapy, and she died within one year. Although flower-like nuclei are typical of adult T-cell lymphoma/leukemia, similar multilobated nuclei may occur in DLBCL. Although multilobated DCBCL have been reported to have a better prognosis than other forms of DLBCL, the abovementioned translocations may have contributed to the patient's aggressive clinical course.

We herein report a 26-year-old man diagnosed with Wilson's disease (WD), initially treated for schizophrenia for 11 years. At 26 years old, he was admitted because of status epilepticus. Brain magnetic resonance imaging revealed frontal-dominant leukoencephalopathy with cystic changes and basal ganglia atrophy. The diagnosis of WD was confirmed based on neuropsychiatric symptoms, Kayser-Fleischer rings, abnormal copper metabolism, and a genetic analysis of ATP7B. Psychotic symptoms in WD can precede neurological manifestations, and extrapyramidal signs may be mistaken for drug-induced Parkinsonism. WD should be considered in patients presenting with progressive Parkinsonism preceded by schizophrenia-like psychiatric symptoms.

We herein report the first case of dyspnea with hemidiaphragm elevation in a 68-year-old woman with active giant cell arteritis (GCA), including successful treatment. Contrast-enhanced computed tomography showed a reduced density of the left ophthalmic artery and the left superficial temporal artery with increased soft tissue compared to the other side, indicating that the GCA had flared up and suggesting that the hemidiaphragm elevation might be caused by vasculitis-associated ischemia of the right phrenic nerve. Hemidiaphragm paralysis due to vasculitis-associated ischemia in patients with GCA needs to be distinguished from local infection, tumors, and hepatomegaly, which are the major causes of hemidiaphragm elevation.

A woman in her late 70s presented with a fever, rashes, and marked proximal muscle weakness. Noninfectious conditions, including myositis and vasculitis, were initially considered. Treatment with cephalosporins was ineffective, but the symptoms improved with minocycline, indicating possible Japanese spotted fever (JSF) despite no apparent history of tick exposure. The diagnosis was confirmed by serological tests. A skin biopsy revealed leukocytoclastic vasculitis with immune complex deposition, suggesting muscle damage due to immune complexes. This case underscores the need to consider JSF in patients with atypical symptoms and initiate timely treatment to prevent severe complications.