Recent advances in endoscopic equipment have improved the diagnosis of gastrointestinal tumors. Image-enhanced endoscopy, including narrow-band imaging, blue light imaging, and linked color imaging, has unified magnifying observation classification methods and significantly improved the qualitative and quantitative diagnostic performance of gastrointestinal epithelial tumors. Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early-stage gastrointestinal cancer, is widely used. The aging population in Japan has been gradually increasing. Despite this, ESD has shown good outcomes in older adults. However, long-term prognostic analyses should take into account the high mortality rate from other illnesses. Prognostic indicators such as the Charlson Comorbidity Index (CCI) and the Prognostic Nutrition Index (PNI) should be used to determine whether ESD should be performed. Even in cases of noncurative resection, follow-up without additional surgical resection is an option if there are other comorbidities that affect the prognosis.

Despite antiviral administration, a small number of patients still suffer from prolonged and severe COVID-19 owing to excessive inflammation. Traditional Kampo medicines (TKMs) with a heat-clearing effect have anti-inflammatory effects, such as a reduced NF-κB activity, and rarely cause serious side effects when administered for a short period of time. After oral administration, TKMs interact with the gut microbiota, producing two types of metabolites: metabolites from the gut microbiota (of food and host origin) and TKM compounds transformed by the gut microbiota. Both metabolites decreased the levels of pro-inflammatory cytokines. TKM compounds transformed by the gut microbiota may exhibit superior bioavailability compared with their precursors. In this review, we assessed the mechanism by which bioactive substances with anti-inflammatory effects, such as berberine, baicalin, saikosaponin, kaempferol, and short-chain fatty acids, are effective in treating respiratory symptoms after COVID-19 infection.

Objective This retrospective study assessed the longitudinal prognostic accuracy of the Model for End-Stage Liver Disease (MELD), MELD-Na, MELD 3.0, and Child-Pugh scores in predicting mortality and rebleeding risk in patients with liver cirrhosis (LC) following successful endoscopic hemostasis for acute variceal hemorrhaging (AVH).

Methods Time-dependent receiver operating characteristics and survival analyses were performed to predict mortality. The risk of rebleeding was analyzed using a competing risk model.

Patients A total of 168 patients with LC who underwent successful endoscopic treatment, including ligation and sclerotherapy for AVH of the esophagus or stomach, were included.

Results The MELD 3.0, which demonstrated the highest accuracy for predicting mortality, had an average area under the curve of 0.789, remaining above 0.8 for up to 18 months. The survival rate was significantly worse in the high-MELD group (3.0) than in the low-MELD group (3.0), with a hazard ratio (HR) of 3.23 and a shorter median survival time of 113 days versus 1,750 days. Advanced hepatocellular carcinoma and the need for red blood cell transfusion were also independent risk factors for mortality. A high MELD-Na level was the only factor associated with an increased risk of rebleeding (HR, 2.07), and the cumulative rebleeding rate was significantly higher in the high-MELD-Na group than in the low-MELD-Na group.

Conclusion MELD 3.0 and MELD-Na serve as reliable non-invasive tools for predicting the long-term mortality and rebleeding risk after AVH. These scores can aid in clinical decision making, enabling the early identification of high-risk patients for targeted interventions and closer monitoring.

Objective Sex differences in fasting glucose levels or the prevalence of impaired fasting glucose (IFG) have been observed in various populations and ethnic groups, suggesting potential variations in the pathophysiology of diabetes between men and women. However, limited research has focused on sex disparities in fasting glucose levels among non-diabetic Asian populations. This cross-sectional study investigated sex differences in fasting glucose levels among non-diabetic Japanese individuals who underwent the 75-g oral glucose tolerance test (OGTT).

Methods The population analyzed comprised 176 men and 185 women, all of whom were Japanese without diabetes. Individuals with diseases or medications that affect glucose metabolism were excluded from the study. Fasting glucose and insulin levels were measured after a 12-h fast and during a 75-g OGTT. Subcutaneous and intra-abdominal fat areas were assessed using computed tomography. A multiple linear regression analysis was used to evaluate the association between sex and fasting glucose levels after adjusting for potential confounders.

Results There were significantly more isolated IFG in men than in women, and men had significantly higher fasting glucose levels than women. The association between sex and fasting glucose remained significant, even after adjusting for the age, BMI, intra-abdominal fat area, subcutaneous fat area, intra-abdominal fat area/subcutaneous fat area ratio, insulinogenic index, homeostasis model assessment for insulin resistance (HOMA-IR), and 2-h glucose.

Conclusion Among non-diabetic Japanese, the fasting glucose level was statistically significantly higher in men than in women, suggesting potential sex-specific variations in glucose metabolism. This sex difference was independent of the fat distribution, insulin secretion, and insulin sensitivity.

Objective The present study investigated the various clinical effects of dapagliflozin in chronic kidney disease (CKD) and its efficacy in patients with advanced renal dysfunction.

Methods A total of 94 CKD cases (non-diabetic, 58; diabetic, 36) were treated with dapagliflozin (10 mg/day) in an outpatient setting for 12 months. The estimated glomerular filtration rate (eGFR) was measured during the 12 months before and after, with laboratory findings determined at the baseline and at 12 months after dapagliflozin administration. In addition, the annual decrease in the eGFR (eGFR slope) was compared before and one year after the baseline readings, and the eGFR slope values before and after dapagliflozin administration in 34 rapid decliner cases with an eGFR slope >5 mL/min/1.73 m²/year before dapagliflozin administration and 19 cases with an eGFR <25 mL/min/1.73 m² at baseline were compared.

Results The body mass index, blood pressure, uric acid, and urine protein-to-creatinine ratio significantly decreased, and hemoglobin levels significantly increased after dapagliflozin administration. There was a significant increase after administration in the mean eGFR slope of all cases, rapid decliners, and cases with an eGFR <25 mL/min/1.73 m² at baseline (all p<0.001). Furthermore, there was a higher ratio of improvement in the eGFR slope in 39 patients who underwent multidisciplinary care within 1 year of dapagliflozin administration.

Conclusion Dapagliflozin is effective in preventing renal function decline in patients with rapidly worsening or advanced CKD, with the effect further enhanced after combination with multidisciplinary care.

Objective Endobronchial ultrasound with a guide sheath (EBUS-GS) is used to accurately position a bronchoscope in lung lesions using a guide sheath. Previous studies have focused on diagnostic success as the endpoint. The achievement of 'within' defined as reaching the lesion, is considered crucial in EBUS-GS procedures. This study investigated cases wherein 'within' is likely to be achieved and cases that can be diagnosed after achieving 'within'.

Methods This retrospective study evaluated 258 bronchoscopic examinations using EBUS-GS. We analyzed the relationship between patient background, lesion size and characteristics, achieving 'within', definitive diagnosis after achieving 'within', and complications.

Results A multivariate analysis revealed that a lesion size ≥20 mm [odds ratio 12; 95% confidence interval (CI): 6.0-21; p<0.01] and the presence of solid components (odds ratio 13; 95% CI: 1.3-120; p=0.03) were significantly associated with achieving a "within" status. Among cancer cases, lesions ≥20 mm had a higher diagnostic yield after achieving "within" compared with smaller lesions (odds ratio 4.23; 95% CI: 1.38-12.9; p=0.01). The occurrence of complications was also associated with lesion size ≥20 mm (odds ratio 2.7; 95% CI: 1.02-6.9; p=0.045).

Conclusion Lesion size ≥20 mm and the presence of solid components were key factors associated with achieving "within" during bronchoscopy via EBUS-GS. Larger lesions were linked to a higher rate of definitive diagnosis. Overall, lesion size played a major role in improving diagnostic performance, both in achieving "within" and in successfully obtaining a diagnosis once "within" was achieved.

Objective Acute pleural empyema, defined as empyema diagnosed within three months of the onset, frequently affects patients with poor general health and often poses challenges for invasive treatments requiring general anesthesia. In addition, the number of respiratory surgeons was insufficient and unevenly distributed across urban base and core hospitals in Japan. Therefore, safe and effective therapeutic procedures that physicians can perform are required.

Methods We retrospectively analyzed 28 patients with acute pleural empyema who underwent decortication using medical thoracoscopy under local anesthesia (DMT-LA) in our department. All procedures were performed by respiratory physicians at our institution. The "success" of DMT-LA was defined by meeting all of the following criteria: (i) absence of residual clinically significant pleural effusion, (ii) resolution of clinical signs of sepsis, (iii) normalization of serum C-reactive protein (CRP) levels and white blood cell counts, (iv) no requirement for additional interventions, and (v) maintenance of these conditions for at least one month following antibiotic treatment.

Results Of the 28 patients, 21 met the criteria for success, yielding a success rate of 75.0%. Patients in the failure group were more likely to have an Eastern Cooperative Oncology Group-performance status of >3, stage III empyema, and high median serum CRP levels than those in the success group. Adverse events were observed in only one patient (3.4%) and involved prolonged sedative effects.

Conclusion DMT-LA is a safe and effective therapeutic procedure that can be performed by respiratory physicians and provides a viable treatment option for acute pleural empyema, particularly in facilities without respiratory surgeons.

Objective Patients with acute myeloid leukemia (AML) transformed from myelodysplastic syndrome (MDS) have a poor prognosis, including those treated with azacitidine during the MDS phase; there is no standard for the care of these patients. Recently, azacitidine plus venetoclax (AZA/VEN) was reported to prolong the survival in treatment-naïve AML patients compared with AZA monotherapy. However, the results of AZA/VEN for AML transformed from MDS, particularly after AZA monotherapy, remain unclear. The present study therefore compared the clinical results of AZA/VEN treatment in these patients.

Methods Data from MDS patients diagnosed at 10 institutions in Nagasaki Prefecture were collected. Thereafter, patients with transformed AML following AZA monotherapy during the MDS phase were selected, and their treatment response and survival were analyzed.

Results The overall response (OR) rate, overall survival (OS), and event-free survival (EFS) were compared among patients treated with AZA/VEN (n=13), chemotherapy (intensive and low-intensity, n=35), AZA monotherapy (mAZA, n=15), and best supportive care (BSC, n=43) after AML transformation. The corresponding OR rates were 38.5%, 20.0%, and 6.7% for the AZA/VEN, chemotherapy, and mAZA groups, respectively (p=0.235). The respective median OS and EFS were 10.7 and 8.9 months for AZA/VEN, 3.2 and 2.0 months for chemotherapy, and 3.8 and 2.7 months for mAZA, and 1.7 months for BSC (OS only) (p=0.000023 for the OS and p=0.026 for the EFS),

Conclusion Our findings suggest the superiority of AZA/VEN for AML patients with transformation from MDS following AZA monotherapy.

Hepatic ectopic adrenal glands are rare and can mimic hepatocellular carcinoma (HCC). We herein report a 60-year-old woman with a history of chronic hepatitis C who achieved a sustained virological response. A 23-mm hepatic lesion was detected and initially diagnosed as HCC. However, laparoscopic resection and histopathology confirmed the presence of an ectopic adrenal gland. Given the location of the posterior liver, a biopsy is challenging. Adrenal scintigraphy may aid in the diagnosis and reduce the need for invasive procedures. As more cases are reported, improved imaging-based diagnoses may facilitate noninvasive identification of hepatic ectopic adrenal glands, avoiding unnecessary surgical intervention.

Spontaneous regression (SR) of pancreatic neuroendocrine tumors (pNETs) is extremely rare. We herein report a 64-year-old man with a nonfunctioning pNET that was incidentally detected during an evaluation for back pain. Imaging showed a 30-mm mass in the pancreatic tail, but surgery was delayed because of an old myocardial infarction. Four months later, follow-up imaging revealed tumor shrinkage of 20 mm without treatment. Laparoscopic distal pancreatectomy confirmed a grade 3 pNET. While ischemia was considered, factors such as mild immune response or metabolic stress may have contributed. This case suggests that ischemia and other factors may also play a role. Further research is needed to elucidate the mechanisms underlying SR in neuroendocrine tumors.

A 62-year-old woman presented with jaundice and fatigue. A blood examination revealed markedly elevated serum transaminase and bilirubin levels and negative hepatitis virus markers. A radiographic examination revealed no bile duct abnormalities. Serum transaminase levels decreased and normalized without immunosuppression after transcatheter arterial embolization and splenectomy for spontaneous splenic rupture, respectively. The pathological findings of the liver biopsy specimens were consistent with those of acute-onset autoimmune hepatitis (AIH), despite normal serum IgG levels. The clinical course of the present case suggests that pathogenic immune responses associated with acute-onset AIH may arise in the spleen, but not in the liver.

There are no established guidelines for managing patients with rare but fatal ruptured splenic abscesses. In this clinical scenario, open splenectomy seems to be a standard literature-based intervention. However, open splenectomy under general anesthesia is not a priority in high-risk surgical patients. We herein report an endoscopic ultrasound-guided transmural dual drainage combined with lavage and intermittent negative pressure drainage as an alternative to surgery for a critical patient with a ruptured splenic abscess and discuss the benefits and drawbacks of open splenectomy as a case report and literature review.

The optimal endoscopic treatment for foveolar-type gastric tumors with raspberry-like appearance remains unclear. A 51-year-old man underwent endoscopic treatment for a 4-mm foveolar-type gastric tumor with a raspberry-like appearance. Because the patient preferred outpatient treatment, resection was performed using cold forceps polypectomy with jumbo forceps. Both the gross and pathological margins were negative, and the tumor was successfully resected without complications. This case suggests that cold forceps polypectomy with jumbo forceps may be a suitable and minimally invasive treatment for small foveolar-type gastric tumors with a raspberry-like appearance.

Afatinib is a second-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor approved for the treatment of non-small-cell lung cancer. We herein report a 61-year-old woman who developed dyspnea and ventricular tachycardia (VT) after afatinib treatment for lung adenocarcinoma. Following restoration of sinus rhythm with continuous amiodarone infusion, echocardiography and cardiac computed tomography revealed Takotsubo-like left ventricular wall motion abnormalities. Unfortunately, the patient's cardiac function did not improve, and she developed circulatory failure, which resolved on day 3 of hospitalization. Takotsubo-like cardiac dysfunction and VT should be recognized as potential side effects of afatinib.

This case report describes an 80-year-old man with severe immunoglobulin G4-related tubulointerstitial nephritis (IgG4-TIN), characterized by storiform fibrosis with diffuse lymphocytic and plasma cell infiltration observed on a renal biopsy. Steroid pulse therapy administered immediately after confirming a remarkable increase in urinary β2-microglobulin (100,948 μg/L) along with no evidence of malignancy significantly improved the renal function and reduced the urinary β2-microglobulin levels. This study highlights the potential utility of urinary β2-microglobulin as a biomarker for early treatment selection in severe IgG4-TIN and emphasizes the need for timely intervention to prevent irreversible kidney damage.

Autosomal dominant Alport syndrome (ADAS), which leads to kidney dysfunction, is primarily associated with heterozygous mutations in COL4A3/4. Mitochondrial disease can also lead to kidney dysfunction. We report a rare case of a 29-year-old woman with ADAS and mitochondrial nephropathy, identified through a genetic analysis, revealing a novel in-frame deletion in COL4A3 and a mitochondrial m.3243A>G mutation. Kidney biopsy revealed basement membrane thinning and mitochondrial nephropathy. Treatment with taurine, arginine, and finerenone improved her proteinuria. This case highlights the complexity of diagnosing genetic kidney diseases and underscores the importance of next-generation sequencing in guiding personalized medicine for optimal and precise management.

An 84-year-old woman undergoing hemodialysis for autosomal dominant polycystic kidney disease (ADPKD) was admitted for refractory hepatic cyst infection. Magnetic resonance cholangiopancreatography and contrast-enhanced computed tomography revealed a concurrent complication of Caroli disease, diagnosed by cystic dilatation of the intrahepatic bile duct and a central dot sign in the vicinity of the infected liver cyst. However, there was no traffic between the infected liver cyst and dilated bile duct, and the cyst drainage procedure was curative. In cases where both diseases were combined, it was suggested that two infections, cyst and biliary tract infections, could occur.

Established fibrosis in pulmonary sarcoidosis is typically not progressive. However, progressive fibrosis similar to interstitial pneumonia occasionally occurs. We herein report a 49-year-old woman who was histologically diagnosed with sarcoidosis. She also had honeycomb-like manifestations in the lower lobes that resembled idiopathic pulmonary fibrosis on computed tomography, whereas pathological findings of a surgical lung biopsy suggested interstitial lung disease associated with rheumatoid arthritis. However, the patient did not develop clinical rheumatoid arthritis even after 17 years of follow-up. Notably, she showed progressive fibrosis and was treated with anti-fibrotic therapy. It is thus important to recognize progressive fibrosis in pulmonary sarcoidosis, although it is rare.

Alemtuzumab-based conditioning for allogeneic hematopoietic stem cell transplantation (allo-HSCT) effectively reduces graft rejection but may predispose patients to autoimmune complications. We herein report a 30-year-old man with severe aplastic anemia who developed thyroid storm due to autoimmune thyroiditis 6 months after undergoing allo-HSCT with an alemtuzumab-based regimen. Despite prompt engraftment, mixed T-cell chimerism and insufficient immune regulation may have contributed to the early onset and severity of the thyroid storm. Careful monitoring of the thyroid function and immune chimerism might facilitate the early detection and management of post-transplant autoimmune complications, including thyroid storm, in patients receiving alemtuzumab-based conditioning.

Hashimoto's encephalopathy (HE) is a type of encephalopathy characterized by neuropsychiatric symptoms, high serum anti-thyroid antibody concentrations, and good responsiveness to immunotherapy. We herein report a rare case of HE with positive serum anti-NH₂ terminal of α-enolase (NAE) antibodies and abnormal findings in the bilateral basal ganglia on brain magnetic resonance imaging. In cases presenting with isolated lesions in the basal ganglia, HE should not be excluded from the differential diagnosis, particularly when other causes are excluded and serum anti-thyroid antibodies are elevated. In such cases, testing for anti-NAE antibodies may aid in the diagnosis.

A 52-year-old woman with myalgia, anti-aminoacyl tRNA synthetase, anti-SS-A/Ro52 antibody positivity, and elevated creatine kinase levels was admitted to our hospital. She was diagnosed with Sjögren's disease (SjD) complicated by polymyositis (PM). No chest symptoms were observed. Although her electrocardiogram and echocardiogram findings were normal, cardiac magnetic resonance imaging (CMRI) revealed myocardial edema and fibrosis with late gadolinium enhancement, elevated extracellular volume, and elevated T2 values. After treatment with prednisolone, the myalgia and CMRI abnormalities improved. This case suggests that CMRI may be useful for the detection and treatment of subclinical myocardial damage in patients with SjD complicated by PM.

A 58-year-old woman with schizophrenia was transported to our hospital by ambulance due to impaired consciousness. At the time of the examination, the patient had significant abdominal distension and diabetic ketoacidosis associated with urinary retention. Although the symptoms improved with the insertion of a urinary catheter and glycemic control, the involvement of the antipsychotic olanzapine was considered the background to the pathophysiology of this case. We herein report the relationship between antipsychotic drugs, diabetic ketoacidosis, and urinary retention along with a literature review.