Objective ResMed has recently developed new continuous positive airway pressure (CPAP) devices, namely the AirSense 11 series. This study aimed to determine whether new ResMed devices have a more favorable impact on CPAP therapy than previous models.

Methods This prospective multicenter study was conducted at Kyoto University Hospital, Rakuwakai Otowa Hospital, Shibata Clinic, and Hatta Medical Clinic. Patients with sleep apnea syndrome who used the previous generation of ResMed devices and switched to new ResMed devices from April 2023 to June 2024 were eligible to participate in the study. CPAP device data for one month before and after switching to new ResMed devices were downloaded using ResScan, NemLink, or f'Rens.

Results A total of 102 patients were included in this analysis. The switch from old to new ResMed devices resulted in significant decreases in median CPAP pressure and 95th percentile leak from 8.1 (6.8-9.9) cmH₂O to 7.4 (6.2-8.8) cmH₂O (p<0.0001) and from 25.2 (14.4-36.2) L/min to 21.9 (14.4-33.8) L/min (p=0.0034), respectively. The percentage of CPAP therapy used for at least 4 h increased from 86% (56.1-94.3%) to 90% (60-100%) (p=0.0043). Meanwhile, the switch to new ResMed devices did not affect the apnea-hypopnea index [1.7 (0.9-2.9) events/h vs. 1.3 (0.7-2.6) events/h, p=0.092].

Conclusion The new ResMed device had favorable effects on CPAP therapy. The effects of different devices from the same manufacturers, as well as those from different manufacturers, on CPAP therapy should be carefully investigated.

Objective This study aimed to clarify the clinical features and effective treatments for localized otitis media-associated vasculitis (OMAAV).

Methods We conducted a single-center retrospective study, classifying the patients into localized OMAAV and systemic OMAAV groups, based on the OMAAV diagnostic criteria, and compared their clinical features, laboratory findings, clinical course, treatment, and hearing prognosis. We also assessed any tympanic membrane findings suggestive of vasculitis using the scoring system of the OMAAV tympanic membrane (SCOT).

Results We collected data from 20 OMAAV patients between January 2013 and July 2023. Seventy percent of the patients visited the otolaryngology department as their first consultation, with a median period of 2.5 months from the onset of ear symptoms to diagnosis. Compared to systemic OMAAV, localized OMAAV had fewer systemic symptoms, such as high fever, and the markers of inflammation were also lower. The positivity rate of ANCA was similar between the groups, and 90% of the cases with localized OMAAV were positive for MPO-ANCA. The combination rate of glucocorticoids (GC) and immunosuppressants (IS) in localized OMAAV was high (80%), and the initial dosage of GC was similar to that in systemic OMAAV. Regarding the treatment outcomes, the rate of hearing improvement was high at 75%, and no patients experienced a relapse of localized OMAAV.

Conclusion An early diagnosis of localized OMAAV requires the recognition of tympanic membrane findings suggestive of vasculitis and measurement of the ANCA levels. Early aggressive treatment with GC and IS for localized OMAAV can lead to a favorable hearing prognosis.

Objective In 2020, Japan recorded the highest number of computed tomography (CT) units per million population among Organization for Economic Co-operation and Development (OECD) countries. This surplus may lead to unnecessary procedures, increased costs, and increased radiation exposure. This study estimated CT procedures per 1,000 population and analyzed their usage by sex and age using governmental surveys and health insurance claim data.

Methods Data from 2008 to 2020 were obtained from the Ministry of Health, Labour and Welfare medical institution surveys. Age- and sex-specific data (2014-2022) were extracted from the Japanese National Database of Health Insurance Claims and Specific Health Checkups (NDB Open Data, Japan). The population data were sourced from the Ministry of Internal Affairs and Communications.

Results The number of CT procedures performed per 1,000 population increased from 210 in 2008 to 283 in 2020. The number of CT procedures performed per unit increased from 2,170 in 2008 to 2,445 in 2020. NDB Open Data revealed an annual increase in CT procedures per 1,000 population, from 221 in 2014 to 255 in 2022. Men underwent more CT scans than women across all age groups, with CT procedures per 1,000 population increasing with age (e.g. in 2022, 27 in men 0-9 years old to 1,182 in men ≥90 years old and 18 in women 0-9 years old to 835 in women ≥90 years old).

Conclusion The number of CT procedures performed per 1,000 population in Japan has steadily increased. With the highest OECD rates in 2017 and 2020, mitigating overuse requires a dose management system, referral guidelines, and education regarding radiation risks for referring physicians.

Objective To investigate the prevalence of burnout and identify its associated risk factors using structural equation modeling (SEM).

Patients A cross-sectional web-based survey targeting members of the American College of Physicians Japan Chapter (ACP-JC) was conducted in March 2024. The survey included the Mini Z 2.0 for burnout assessment, Emotional Vulnerability Scale, and Japanese version of the Brief Resilience Scale (BRS-J). Descriptive statistics were used to analyze the demographic and workplace characteristics, and SEM with maximum likelihood estimation was employed to explore the relationships between resilience, emotional vulnerability, teamwork, and burnout.

Results Of the 1,066 invited physicians, 103 (9.7%) responded to the survey. Burnout symptoms were reported by 26.2% of the participants. An SEM analysis indicated significant negative associations between resilience (standardized coefficient: -0.29, p=0.007), teamwork (standardized coefficient: -0.32, p<0.001), and burnout, whereas emotional vulnerability showed no significant associations (standardized coefficient: 0.05, p=0.630).

Conclusion Approximately one in four Japanese internists and primary care physicians reported burnout symptoms. Resilience and teamwork have emerged as key protective factors, thus underscoring the importance of fostering supportive workplace environments. Therefore, interventions to enhance resilience and strengthen workplace support systems are recommended to mitigate burnout.

We encountered a case demonstrating a high confluence of the pancreaticobiliary ducts with frequent acute pancreatitis recurrence in the absence of alcohol consumption and gallstones. The patient presented to our hospital after 12 acute pancreatitis episodes and was subsequently admitted with acute pancreatitis which was diagnosed to be severe by computed tomography grade according to the Japanese Ministry of Health, Labour and Welfare severity criteria 2008. After recovery, endoscopic retrograde cholangiopancreatography revealed an 8-mm common duct only during papillary sphincter relaxation; therefore, a high confluence of the pancreaticobiliary ducts was diagnosed. No recurrence of pancreatitis was observed after extrahepatic cholangiectomy or cholecystectomy. A high confluence of the pancreaticobiliary ducts should be considered when patients present with recurrent pancreatitis. Additionally, surgery should also be considered in such cases.

A man in his 60s with alcoholic cirrhosis experienced repeated gastrointestinal bleeding, and endoscopy revealed angiodysplasia hemorrhaging in the stomach and duodenum. A systolic murmur was heard, and cardiology consultation resulted in the diagnosis of severe aortic stenosis and Heyde syndrome. Gastrointestinal bleeding was resolved after surgical aortic valve replacement. Gastrointestinal bleeding often occurs in patients with cirrhosis and a cardiac examination is recommended if angiodysplasia is observed. This case also suggests that the von Willebrand factor, which is involved in Heyde syndrome, is also closely associated with liver disease.

Hepatitis E virus (HEV) is a globally prevalent waterborne and zoonotic infection, with approximately 20 million infections occurring annually in developing and industrialized countries. Reported here are the details of a 73-year-old Japanese man who contracted HEV subtype 3e after consuming self-prepared pork liver from a domestically raised pig and presented with severe liver enzyme elevation. Conservative treatment, including hepatoprotective therapy and Inchinkoto, an herbal medicine, was administered for prolonged jaundice, and recovery was achieved. Owing to the long incubation period and nonspecific symptoms, routine HEV testing is crucial for the differential diagnosis of acute liver failure to provide appropriate management.

We herein report two cases of pancreatic mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs). Case A was a mixed ductal-neuroendocrine cell carcinoma with a KRAS mutation and loss of RB1 and SMAD4 expression. Case B was a mixed acinar-neuroendocrine cell carcinoma with wild-type KRAS and loss of p16 and SMAD4 expression. The expression of RB1 and ARID1A was also reduced. These results support the recently proposed classification of neuroendocrine carcinoma into ductal and acinar types based on molecular features, which may facilitate the understanding and development of specific treatments for this intractable tumor.

Desmoplastic small round cell tumor (DSRCT) is a rare and aggressive malignancy with a poor prognosis. We report an autopsy case of DSRCT in a 24-year-old male with a rapidly fatal outcome due to unusual diffuse cystic liver metastases. Despite an initial complete response to therapy, the patient developed extensive hepatic involvement leading to acute liver failure. Autopsy revealed widespread DSRCT with cystic degeneration in the liver metastases, which was confirmed by EWSR1 rearrangement. This case highlights the unpredictable nature of DSRCT and its potential for an atypical presentation, while emphasizing the need for improved therapeutic strategies.

A 73-year-old man with a 13-year history of methotrexate (MTX) therapy for rheumatoid arthritis presented with jaundice and hepatic dysfunction. Contrast-enhanced computed tomography revealed hypovascular masses in the pancreas, small intestine, and thyroid lobes. A biopsy confirmed diffuse large B-cell lymphoma (DLBCL), leading to the diagnosis of MTX-associated lymphoproliferative disorder (MTX-LPD), a rare condition with pancreatic involvement. MTX was discontinued and R-CHOP therapy was initiated. Although a spontaneous regression of MTX-LPD can occur, early intervention may be warranted in select cases, thus highlighting the need for an individualized management approach.

A man in his 80s who was on maintenance dialysis and warfarin therapy for atrial fibrillation developed sudden mottled cyanosis and multiple ulcers on his toes, without any apparent trigger. Despite no significant stenosis in the lower extremity arteries, he had a shaggy mural thrombus in the abdominal aorta, leading to a diagnosis of blue toe syndrome. Conservative treatment was ineffective, prompting the use of a novel apheresis device (Rheocarna^®; Kaneka, Osaka, Japan) for direct blood adsorption therapy. This intervention resulted in the healing of his toe ulcers. Blue toe syndrome is often refractory with no established treatment. The Rheocarna^® device shows promise as a potential therapeutic option.

We herein report a case of pacemaker lead-related tricuspid regurgitation in a repaired congenital heart disease patient, with a significant improvement in exercise tolerance and liver stiffness after surgery. Optimizing the timing of invasive procedures for tricuspid regurgitation is challenging because of an insufficient ability to predict the outcome, and percutaneous therapies have shown promising advancements in recent years. In this case, close monitoring with abdominal ultrasound and echocardiography facilitated our ability to select the optimal timing for surgical intervention.

Ornithine transcarbamylase deficiency (OTCD) is a disorder of the urea cycle. A 19-year-old man with no medical or family history presented with sudden alterations in mentation after weight training and increased protein intake. His plasma ammonia level increased to >235 μmol/L, and intensive blood purification therapy was promptly initiated based on the assumption of acute hyperammonemic encephalopathy due to late-onset OTCD. On day 5, his mental status and plasma ammonia levels normalized, allowing discontinuation of blood purification therapy. An amino acid analysis confirmed the presence of OTCD. Prompt and intensive blood purification therapy is necessary to treat hyperammonemic encephalopathy due to late-onset OTCD.

A 75-year-old never-smoker woman presented with dyspnea and loss of appetite. A mass was identified in the left upper lobe of the lung, and the patient was referred to our hospital. Despite the diagnosis of lung adenocarcinoma via bronchoscopy, anaplastic lymphoma kinase (ALK) immunostaining was negative. Rapid weight gain and abdominal distension caused by ascites prompted fluid testing using the AmoyDx^® Pan Lung Cancer PCR Panel. EML4-ALK fusion was confirmed, and alectinib therapy was initiated immediately. The tumor size had decreased significantly, and the patient was discharged on day 34. This case highlights the necessity of multiplex genetic testing even when ALK immunostaining is negative.

The aspiration or inhalation of lipid substances can cause lung injury, including chemical pneumonitis and exogenous lipoid pneumonia. We herein report a case of acute lung injury caused by kerosene inhalation in a tent sauna. A patient developed dyspnea with respiratory failure two hours after igniting a wood-burning stove with kerosene. High-resolution computed tomography revealed widespread ground-glass opacities, and bronchoalveolar lavage revealed lipid-laden macrophages. Systemic corticosteroid treatment led to a rapid improvement. Although kerosene is generally safe at room temperature, its vaporization in high-temperature environments may increase the risk of lung injury through inhalation.

A 66-year-old woman who had been diagnosed with sarcoidosis 1 year prior to identifying a non-caseating granuloma in the nodule in her femur fell into a state of presyncope and had difficulty breathing. She was transported to the emergency department and placed on mechanical ventilation. A blood gas analysis suggested CO₂ narcosis. The cause was thought to be ventilatory failure due to muscular sarcoidosis, for which systemic steroid treatment was initiated. Although her consciousness recovered, the ventilatory impairment persisted. This case demonstrates an unusual clinical presentation of life-threatening nodular and myopathy types, characterized by the development of Type II respiratory failure.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is known for its feasibility and tolerability for diagnosing intrathoracic lesions. EUS-B-FNA is less invasive and potentially more productive than endobronchial ultrasound-guided transbronchial needle aspiration, which involves a transairway biopsy of mediastinal lesions. We herein report five patients with lymphoid tumors who were diagnosed using EUS-B-FNA without any complications. Our experience suggests that EUS-B-FNA may be useful in the diagnosis of lymphoid tumors.

A 58-year-old Japanese man presented at our hospital with respiratory failure. Computed tomography (CT) revealed scattered fat-attenuated consolidations, and bronchoalveolar lavage fluid (BALF) showed neutrophilia, leading to a diagnosis of exogenous lipoid pneumonia (ELP) caused by the excessive use of a menthol-containing nasal inhaler. Despite a temporary improvement, the patient experienced recurrent respiratory failure shortly after discharge. CT revealed centrilobular ground-glass opacities, and a bronchoalveolar BALF analysis revealed lymphocytosis, suggesting acute hypersensitivity pneumonitis (AHP) triggered by domestic environmental antigens. Antigen avoidance was successful and remission was maintained. The rare sequential occurrence of AHP following ELP suggests a potential pathophysiological connection between these conditions.

The poor prognosis of lung cancer during pregnancy requires complicated management. A 40-year-old woman at 25 weeks' gestation was admitted with persistent back pain. Imaging findings suggested lung cancer. A multidisciplinary team determined that early intervention was crucial, and Caesarean delivery was performed at 27 weeks' gestation. Thereafter, the patient was diagnosed with lung adenocarcinoma with bone metastasis. The patient underwent rapid opioid titration and radiation therapy for the bone metastases. We then introduced chemotherapy and offered an advanced care plan. A multidisciplinary approach is essential for pregnant women with lung cancer. Early delivery is recommended to expedite the diagnosis and treatment.

A 23-year-old woman with ulcerative colitis (UC) presented with fever, headache, an altered mental status, and bloody stool. A neurological examination, magnetic resonance imaging, and electroencephalography revealed right-side dominant encephalopathy. Although a serological analysis revealed a primary cytomegalovirus (CMV) infection, the cerebrospinal fluid (CSF) showed no evidence of a viral load, although the CSF interleukin-6 levels were markedly elevated (1,670 pg/mL). Encephalopathy rapidly improved with steroid therapy; however, the presence of bloody stool persisted. A colon biopsy revealed concurrent CMV enteritis, which improved with ganciclovir. This case shows that steroid-responsive encephalopathy can occur during a primary CMV infection. Additionally, CMV enteritis complicated by a primary CMV infection should be considered in patients with UC.

IgG4-related disease (IgG4RD) is a chronic inflammatory condition that can mimic malignancies. This report describes an 83-year-old male diagnosed with IgG4RD, in whom a left kidney mass was incidentally discovered. Despite glucocorticoid treatment for IgG4RD, the mass did not shrink, and imaging could not exclude malignancy, prompting surgical resection. Pathological examination revealed a rare benign tumor, renal anastomosing hemangioma (AH) with numerous IgG4-positive cells surrounding it. This case raises the possibility that chronic interstitial inflammation associated with IgG4RD may contribute to the development of renal AH, underscoring the need for further research with additional cases to better understand this relationship.

An 80-year-old woman with sudden generalized convulsions was admitted to our hospital. She had a 33-year history of rheumatoid arthritis. Head magnetic resonance imaging (MRI) at the time of admission showed characteristic leptomeningeal findings, and the anti-cyclic citrullinated peptide antibody (ACPA) titer in the cerebrospinal fluid (CSF) was elevated, thus leading to a diagnosis of rheumatoid meningitis (RM). After glucocorticoid treatment, the patient's symptoms promptly improved. RM is often diagnosed using a meningeal biopsy and MRI; however, recent reports have suggested that the CSF ACPA titers (antibody titer index) may also be elevated. In this case, CSF ACPA was useful for making a diagnosis and selecting the optimal treatment modality.

This case report describes a 70-year-old female with cancer of unknown primary origin (CUP) who exhibited multiple distant lymph node metastases. Despite conventional chemotherapy (carboplatin and paclitaxel) and immunotherapy (nivolumab), disease progression was noted. Genomic profiling revealed MET amplification, leading to the administration of capmatinib, a selective MET tyrosine kinase inhibitor. The patient experienced substantial tumor reduction with dose adjustments due to adverse effects, indicating the potential efficacy of capmatinib in treating CUP with MET amplification.