Olanzapine, a widely prescribed atypical antipsychotic, is associated with significant metabolic side effects including hyperglycemia and new-onset diabetes mellitus. While it often contributes to or mimic conventional type 2 diabetes through weight gain and insulin resistance, olanzapine can also induce a distinct, acute, ketosis-prone form of diabetes characterized by acute, severe hyperglycemia, and a high risk of diabetic ketoacidosis (DKA). This review summarizes the current understanding of olanzapine's multifaceted diabetogenic mechanisms, distinguishing its contributions to both type 2 diabetes and this severe drug-induced presentation, and emphasizes the critical implications for patient management, particularly concerning the acute manifestations of DKA. We also discuss its unique position within the broader classification of other types of diabetes and drug-induced etiologies.

Objective Monitoring the condition of stool is useful for daily health management and early detection of diseases; however, a self-assessment of stool form is often inaccurate. To address this issue, TOTO, developed a prototype toilet seat equipped with a sensor that classifies stool forms according to the Bristol Stool Form Scale (BSFS). This study aimed to verify the accuracy of this method for distinguishing stool types.

Methods We recruited 38 healthy Japanese participants and obtained BSFS data using the device from November 2021 to March 2022. Meanwhile, we taught the participants how to assess their own stool using the BSFS and used their assessments as reference standards. We evaluated the strength of agreement between the participants' assessments and the device's classification results using the kappa coefficient, as well as the strength of correlation using Spearman's rank correlation coefficient.

Materials We analyzed 305 samples from 38 participants after excluding 62 samples for which the participant's judgment was unreliable or the device data were of a low quality.

Results The kappa coefficient between participants' assessments and the device's classification results based on BSFS was 0.55 [95% confidence interval (CI) 0.45-0.65, p<0.001], while the Spearman's rank correlation coefficient was 0.56 (95% CI 0.48-0.63, p<0.001).

Conclusion The device appeared to possess limited but moderate validity, with fair to good agreement and moderate correlation with the participants' assessment results. This toilet seat with an automated classification of stool form by sensing falling stool may support daily healthcare and early disease detection.

Objective This study aimed to investigate the short-term effect of sodium/glucose cotransporter 2 inhibitors (SGLT2is) on serum magnesium (sMg) across three subgroups stratified according to the severity of albuminuria in patients with type 2 diabetes mellitus (T2DM).

Methods Ninety patients were stratified into three subgroups according to their urinary albumin-to-creatinine ratio (UACR) at the initiation of SGLT2i treatment, according to the severity classification of albuminuria: A1 (normoalbuminuria; n=39), A2 (microalbuminuria; n=30), and A3 (macroalbuminuria; n=21). We evaluated the changes in sMg three months after the initiation of SGLT2i treatment in each subgroup. Subsequently, we compared the changes (Δ) in sMg levels across the three subgroups. Additionally, we investigated the baseline parameters correlated with Δ sMg, as well as the changes in parameters associated with Δ sMg.

Results sMg was significantly increased in all subgroups (p<0.001 for A1, A2, and A3). Δ sMg was significantly different across the three subgroups (p=0.036), and Δ sMg in A3 was significantly greater than that in A1 (p=0.032). Δ sMg was positively correlated with baseline UACR (β=0.244, p=0.040) and inversely correlated with baseline sMg (β=-0.478, p<0.001). Δ sMg was positively correlated with Δ serum albumin level (β=0.239, p=0.033).

Conclusion The short-term effect of SGLT2is on sMg levels was more pronounced in T2DM patients with macroalbuminuria.

Objective Constipation, a clinical form of gut dysbiosis, is highly prevalent in patients undergoing hemodialysis. Patients with chronic kidney disease experience uremia-related changes in the gut environment. Dysbiosis reportedly leads to an atherosclerosis pathogenesis, and constipation is associated with several adverse clinical outcomes including cardiovascular disease and mortality. Phosphate binders, commonly prescribed to patients with end-stage renal disease, bind to non-phosphate molecules and may alter the gut microbiota, potentially leading to systemic effects unrelated to phosphate control, although the clinical evidence is limited.

Methods This cross-sectional study included 293 outpatients undergoing hemodialysis at Masuko Memorial Hospital, Japan. Information about patient characteristics and medication usage was collected, and constipation was assessed using the original diagnostic criteria, incorporating both the Rome IV criteria and a history of laxative use.

Results Of 293 participants, 152 (51.9%) were diagnosed with constipation and 60 (20.5%) had severe constipation. Lanthanum carbonate use was independently associated with a lower risk of constipation [adjusted odds ratio (aOR) 0.55, 95% confidence interval (CI) 0.32-0.94, p=0.029] and a lower risk of severe constipation (aOR 0.41, 95%CI 0.19-0.86; p=0.018), while precipitated calcium carbonate use was associated with a lower risk of severe constipation, independent of age and sex (aOR 0.48, 95%CI 0.26-0.89, p=0.021).

Conclusion Our study highlights the association between specific phosphate binders and a lower risk of constipation. Accordingly, phosphate binders could be selected based on their positive effects on constipation in this patient population.

Objective A quantitative computed tomography (QCT) analysis based on whole-lung density (WLD) histograms helps monitor the state of interstitial lung disease. We investigated the changes in QCT metrics in patients with drug-associated interstitial lung disease (DILD) and their correlation with inflammatory markers.

Methods A QCT analysis using a 3D Slicer software program based on a WLD histogram was performed, excluding patients treated with anticancer agents or those undergoing treatment for malignant tumors to eliminate the effect of tumor size on QCT values. We evaluated the percentages of high attenuation areas (HAA%) at -700 Hounsfield Units (HU) (HAA%-700), -600 HU (HAA%-600), and from -600 to -250 HU [HAA%-(600-250)].

Materials We analyzed patients diagnosed with DILD at our hospital between July 2013 and October 2024.

Results The HAA%-700, HAA%-600, and HAA%-(600-250) values were significantly higher at diagnosis compared to the post-treatment values (28.14±13.60% versus 15.64±9.70%, p=0.0002; 18.45±10.40% versus 9.88±6.26%, p=0.0002; and 14.00±8.14% versus 7.65±4.72%, p=0.0002, respectively). The steroid-treated group had higher inflammatory marker levels than the non-steroid-treated group at the time of diagnosis. The HAA%-600 was significantly higher in the steroid-treated group than that in the non-steroid-treated group (21.42±12.35% vs. 13.18±4.31%, p=0.0128). The HAA%-700, HAA%-600, and HAA%-(600-250) values correlated with the inflammatory marker values.

Conclusion The HAA% values in patients with DILD were significantly higher at diagnosis than after treatment and they also correlated with the inflammatory marker values.

Objective To determine the clinical significance of sputum Pasteurella multocida in adults with structural lung disease by operationally distinguishing infection from colonization and describing outcomes of pathogen-directed therapy.

Methods We performed a single-center, retrospective case study. Infection was defined a priori by new or worsening lower-respiratory symptoms at the time of culture, supported by inflammatory or radiologic changes; isolation without symptoms was classified as colonization. Two pulmonologists blinded to the clinical data reviewed the chest computed tomography scans. Antibiotic selection and clinical responses within 2-4 weeks were extracted from the charts.

Results Seven adults (five women; mean age, 67.1 years) with structural airway disease were included. Middle lobe syndrome and diffuse panbronchiolitis were predominant, while bronchiectasis was present in two patients. Five of the seven patients (71.4%) reported regular dog/cat exposure. Sputum cultures were obtained for acute symptom exacerbations in four patients and for incidental imaging abnormalities in three. Three symptomatic patients received penicillin-class therapy and all improved. One symptomatic patient improved without antibiotics. No recent animal bites or scratches were reported. No severe treatment-related adverse events were observed.

Conclusion In elderly patients with structural airway disease, sputum P. multocida during symptomatic episodes likely represents true infection and responds to targeted narrow-spectrum therapy, whereas asymptomatic isolates may reflect colonization. These observations provide a pragmatic framework to distinguish infection from colonization, support susceptibility-aligned narrow-spectrum management, and offer small-series evidence to inform antimicrobial stewardship in structural lung diseases.

Objective The pathophysiology of right ventricular failure in patients with pulmonary hypertension has not been completely examined and monitoring strategies are lacking. The 14-3-3 protein family plays a regulatory role in cardiac fibroblasts. This study investigated whether 14-3-3 epsilon, a member of the 14-3-3 protein family, was associated with right ventricular failure.

Methods A monocrotaline-induced pulmonary hypertension rat model was used to investigate the role of 14-3-3 epsilon in right ventricular failure. Plasma samples from patients with pulmonary hypertension were analyzed using an enzyme-linked immunosorbent assay for 14-3-3 epsilon.

Patients Right ventricular samples from a monocrotaline-induced pulmonary hypertension rat model and plasma samples (n=83) from patients with pulmonary hypertension were used.

Results The right ventricular 14-3-3 epsilon expression was higher in the monocrotaline group than in the control group. In patients with pulmonary hypertension, the median plasma 14-3-3 epsilon level was 95 ng/mL. Plasma 14-3-3 epsilon levels were significantly associated with tricuspid lateral annular peak systolic velocity and right ventricular fractional area changes in patients with pulmonary hypertension.

Conclusion This is the first study to demonstrate an association between 14-3-3 epsilon and right ventricular failure. Plasma 14-3-3 epsilon level may be a useful circulating marker for evaluating right ventricular dysfunction in patients with pulmonary hypertension.

Objective This study evaluated the efficacy and safety of epcoritamab in real-world clinical practice.

Methods Data of 19 patients who received epcoritamab at Saitama Cancer Center were retrospectively analyzed.

Results The median follow-up duration was 5.6 months. The overall response rate (ORR) was 73.7%, with a complete response (CR) rate of 47.4%. The ORR in patients with prior exposure to bendamustine was 64.3% (CR rate, 50%), and that of bendamustine-naïve was 100% (CR rate, 40%). The ORR in patients with a bendamustine-free period of ≤6 months was 42.9% (CR rate, 28.6%), while that of patients with a bendamustine-free period of >6 months was 85.7% (CR rate, 71.4%). The median progression-free survival (PFS) and overall survival (OS) have not yet been determined, but the values prior to exposure to bendamustine were 6.6 and 7.6 months, respectively. A comparison between the prior bendamustine exposure and naïve groups showed no significant differences in the PFS and OS. In patients with lactate dehydrogenase (LDH) levels of ≤303 U/L at the start of epcoritamab, the median PFS and OS were not yet reached, while in those with LDH levels of >303 U/L, the median PFS and OS were 2.3 and 3.0 months, respectively. Treatment-emergent adverse events (TEAEs) of grade ≥3 severity occurred in 18 of the 19 patients (94.7%), and in 2 of the 19 patients (10.5%), the emergence of TEAEs necessitated treatment discontinuation. Cytomegalovirus (CMV) reactivation occurred in 11 patients (57.9%).

Conclusion Careful attention should be paid to aggressive cases and those with CMV reactivation.

Objective Acquired hemophilia A (AHA) is a rare and often severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Both the prompt diagnosis and treatment of patients with AHA are essential. Data on Japanese AHA diagnostic delay are lacking; therefore, this study aimed to determine the time to AHA diagnosis in Japan, as well as to identify factors influencing the time from presentation to diagnosis.

Methods This web-based, prospective, observational study surveyed physicians in Japan who had diagnosed or treated patients with AHA. The time from bleeding onset to diagnosis was the primary endpoint, with diagnostic testing barriers as the secondary endpoints.

Results Of the 322 physicians who accessed the survey, 112 were included in the study. The time from bleeding onset to referral and from referral to diagnosis was ≥8 days in 31.3% (n=35) and 23.2% (n=26) of cases, respectively. The tests most commonly conducted in-hospital were activated partial thromboplastin time (aPTT) and aPTT cross-mixing tests (85.7% and 73.2%, respectively), for which results typically took <1 day to obtain. FVIII activity and FVIII inhibitor tests were more often outsourced, and when performed in-hospital, the results took ≥2 days in over 25% of cases. Across the tests surveyed, 41.7-76.2% of physicians noted difficulty in interpreting test results as a reason for AHA diagnosis delay.

Conclusion More efficient diagnostic procedures and enhanced physician education and awareness are needed to shorten AHA diagnosis times in Japan.

We report a rare case of intraductal papillary mucinous carcinoma (IPMC) in a young male who initially presented with imaging findings suggestive of autoimmune pancreatitis (AIP) and was later diagnosed with tumor-associated pancreatitis. Despite symptom resolution with conservative treatment, follow-up imaging revealed a pancreatic tumor. Surgical resection confirmed the presence of IPMC with adenocarcinoma components. This case highlights the importance of excluding malignancy even in young patients with AIP-like features. Given the limited sensitivity of FDG-PET for early stage tumors, adjunctive modalities such as endoscopic ultrasound (EUS) and serial pancreatic juice aspiration cytological examination (SPACE) should be actively considered.

This report presents a rare case of 5-aminosalicylic acid (5-ASA)-induced colitis in a 76-year-old man with no history of inflammatory bowel disease (IBD). The patient, who was undergoing treatment for rheumatoid arthritis, developed persistent diarrhea and fever following sulfasalazine (SASP) administration and later experienced a high fever shortly after taking mesalazine. The drug-induced lymphocyte stimulation test result was positive for mesalazine and weakly positive for SASP, thereby supporting the diagnosis of 5-ASA intolerance. This case emphasizes that 5-ASA-induced colitis may occur in patients without IBD. Clinicians should consider this possibility when unexplained gastrointestinal symptoms appear after starting 5-ASA therapy even in patients without any prior IBD.

Gastric glomus tumors are rare and challenging to diagnose preoperatively owing to their resemblance to other submucosal lesions. We herein report the case of a 35-year-old man with a 15 mm gastric submucosal tumor. Endoscopic ultrasonography depicted the tumor as a hyperechoic mass, whereas contrast-enhanced harmonic endoscopic ultrasonography showed homogeneous enhancement and a prolonged contrast effect from the early to delayed phases. Endoscopic ultrasonography-guided fine-needle aspiration showed uniform round cells, and immunohistochemistry confirmed a gastric glomus tumor. This rare gastric glomus tumor was identified preoperatively, thus highlighting the potential of these modalities in diagnosing patients with submucosal gastric tumors.

A 63-year-old woman underwent endoscopic submucosal dissection for early gastric cancer. The lesion initially met the former eCura B criteria but was reclassified as eCura A under the updated Japanese guidelines, which do not recommend routine imaging follow-up. Nineteen months after curative resection, a solitary swollen lymph node was detected on computed tomography and metastasis was histopathologically confirmed. After chemotherapy, the patient underwent a total gastrectomy without residual carcinoma. While such recurrence is rare, this case suggests that clinicians should remain aware of the possibility of lymph node metastasis, even in lesions considered curative under the current criteria.

A 62-year-old woman with poorly controlled type 2 diabetes mellitus presented with a fever and altered consciousness. The patient was diagnosed with diabetic ketoacidosis (DKA) with a positive blood culture for group A Streptococcus. Although the source of infection was initially unclear, contrast-enhanced computed tomography revealed a retropharyngeal abscess (RPA) and descending necrotizing mediastinitis (DNM) that required surgical drainage. RPA with DNM is rare and potentially fatal in adults and is often missed without high clinical suspicion. In severe DKA, altered mental status and hemodynamic instability may obscure the underlying infection, emphasizing the importance of a thorough evaluation.

A 76-year-old woman was diagnosed with acromegaly and underwent resection of a transsphenoidal pituitary tumor. Central hypothyroidism was detected before surgery and the patient was treated with levothyroxine. Insulin-like growth factor-1 (IGF-1) levels remained abnormal after surgery. Follow-up showed an increase in free thyroxine levels even after discontinuation of levothyroxine; thereafter, Marine-Lenhart syndrome was diagnosed. The initiation of treatment with a somatostatin analog for acromegaly and thiamazole for Marine-Lenhart syndrome was followed by normalization of IGF-1 levels and thyroid function test results. Coexistent thyrotoxicosis is rare in patients with acromegaly; therefore, attention should be paid to elderly patients, as they exhibit only a few symptoms.

Fibrin interference can cause spurious immunoassay results, particularly in patients with coagulopathy or those receiving anticoagulant therapy. We report the case of an asymptomatic 79-year-old woman treated with apixaban, who presented spuriously elevated free thyroxine and free triiodothyronine levels, mimicking a syndrome of inappropriate secretion of thyroid-stimulating hormone. Plasma measurements revealed values within the reference range, which confirmed fibrin interference. To our knowledge, this is the first case to demonstrate fibrin interference in thyroid function testing during direct oral anticoagulant therapy. The relevant literature suggests a greater susceptibility to specific free thyroxine assay platforms. Clinicians should recognize this phenomenon to avoid unnecessary investigation of apparent thyroid dysfunction.

2-Hydroxyglutaric aciduria is a rare genetic metabolic disorder, especially in Japan. Although magnetic resonance images show characteristic abnormalities in the subcortical white matter, some cases have been diagnosed in adulthood, namely many decades after onset. We herein report the case of a bedridden 37-year-old 2-hydroxyglutaric aciduria male patient who was diagnosed three decades after onset. Despite this, combination treatment with riboflavin and levocarnitine improved his condition, thus allowing him to walk by himself. Considering our case and the previous literature, we emphasize the importance of correctly diagnosing and treating patients with 2-hydroxyglutaric aciduria.

Scleroderma renal crisis (SRC) and posterior reversible encephalopathy syndrome (PRES) are rare but severe complications of systemic sclerosis (SSc). We report the case of a 44-year-old patient with SSc who developed SRC and PRES, potentially triggered by non-steroidal anti-inflammatory drugs (NSAIDs). The patient presented with impaired consciousness, renal dysfunction, hemolytic anemia, thrombocytopenia, and occipital white matter lesions on magnetic resonance imaging. Treatment included enalapril, hemodialysis, and plasma exchange. This case highlights the potential role of NSAIDs in the development of SRC, and emphasizes the importance of considering NSAIDs as a significant risk factor for SRC in patients with SSc.

A 65-year-old woman with a history of silicone breast implantation was admitted to our hospital with abnormal chest shadows. Although the implants had already been removed, chest CT revealed diffuse ground-glass opacities in both lungs. Thoracoscopic lung biopsy revealed non-necrotizing epithelioid granulomas and silica-phagocytic macrophages, leading to a diagnosis of silicone-implant-associated autoimmune/inflammatory syndrome induced by adjuvants (ASIA). Over a follow-up period of more than 15 years without treatment, the ground-glass opacities improved only slightly. We herein present the longest follow-up chest CT findings of silicone implant-associated ASIA.

We herein report four patients who were unable to receive idecabtagene vicleucel (ide-cel) due to disease progression, despite undergoing leukapheresis within specification. The median age of the patients was 70 (range, 68-77) years old. Two patients had nonsecretory subtypes at the diagnosis. The median number of prior therapy lines was 4.5 (range, 4-6), and 3 patients were penta-refractory. All patients were refractory to the latest treatment. The median time from apheresis to ide-cel cancellation was 44.5 (range: 24-71) days. Our findings suggest that the nonsecretory subtype and penta-refractoriness may increase the risk of treatment discontinuation. Early ide-cel application and improved bridging therapy are warranted to enhance treatment completion after leukapheresis.

Few studies have longitudinally evaluated Hashimoto's encephalopathy with anti-NH₂-terminal α-enolase (anti-NAE) antibodies using detailed imaging and neuropsychological assessments. We present the case of a man in his 50s who presented with acute hallucinations, catatonia, seizures, and cognitive decline. Initial MRI revealed diffuse white matter hyperintensities, and SPECT revealed widespread hypoperfusion. These symptoms improved with immunotherapy, but progressive frontal and temporal atrophy and residual hypoperfusion appeared over 33 months. His cognitive function improved, but he remained impaired, with persistent disinhibition and perseveration. This case suggests that Hashimoto's encephalopathy with anti-NAE antibodies can cause lasting structural and functional brain abnormalities and cognitive impairments, requiring long-term neuroimaging and neuropsychological follow-up.

Alkaptonuria is an organic acid metabolic disorder caused by abnormalities of the tyrosine metabolic pathway. Herein, we report a case of relapsing polychondritis and arthritis in a patient with alkaptonuria and psoriasis vulgaris, respectively. A 53-year-old man, previously diagnosed with alkaptonuria and psoriasis vulgaris, was found to have auricular thickening and tenderness, bilateral bulbar conjunctival injection, and elevated C-reactive protein levels. Ultrasound imaging revealed enthesitis in the bilateral knee joints. A biopsy of the auricular cartilage revealed lymphocytic infiltration. The coexistence of ocular involvement, auricular chondritis, and enthesitis was considered indicative of alkaptonuria complicated by relapsing polychondritis and psoriatic arthritis.

An 81-year-old Japanese man with IgG4-related disease (IgG4-RD) presented with marked edema in the right lower leg. He was diagnosed with IgG4-RD with retroperitoneal fibrosis, hilar and mediastinal lymphadenopathy, elevated serum IgG4 levels, and IgG4-positive plasma cell infiltration in a mediastinal lymph node. Lymphatic scintigraphy revealed an obstruction corresponding to edema due to retroperitoneal fibrosis. Glucocorticoid therapy resulted in rapid improvement. Lymphedema due to IgG4-RD with retroperitoneal fibrosis is rare and no standard treatment exists. This case underscores the importance of considering IgG4-RD which is a potentially reversible cause of lymphedema.

Overwhelming post-splenectomy infection is a life-threatening condition typically caused by Streptococcus pneumoniae. Necrotizing fasciitis is a rare manifestation of invasive pneumococcal disease. A 73-year-old woman with a history of living-donor liver transplantation and splenectomy for primary biliary cholangitis presented with bilateral leg swelling, pain and altered consciousness. S. pneumoniae serotype 7C, sequence type 2758, was isolated from the blood and wound cultures. Despite intensive care and surgery, the patient developed liver graft failure and died on day 42. The emergence of non-vaccine serotypes highlights the urgent need for next-generation vaccines that target emerging strains.

Human metapneumovirus (hMPV), which can cause severe lower respiratory tract disease and, rarely, extrapulmonary complications, was identified in a 64-year-old immunocompetent man who presented with acute hypoxemia, bronchoscopic evidence of diffuse alveolar hemorrhage (DAH), and clinically diagnosed acute myocarditis. Notably, hMPV was detected by multiplex PCR on a bronchoalveolar lavage (BAL) sample despite an initial negative upper airway evaluation. The patient's condition was severe and required invasive mechanical ventilation and inotropic support. After the viral etiology was identified, empiric steroids were discontinued, the patient recovered, and his left ventricular ejection fraction improved from -9% to 40% at discharge. This case underscores the fact that during the hMPV season, acute hypoxemia with diffuse opacities should prompt consideration of infectious DAH and that lower-respiratory multiplex PCR (from BAL or deep tracheal aspirate) can identify pathogens when upper airway tests are negative. It also highlights that, in unexplained DAH, empirical immunosuppression should be used cautiously to perform a full infectious evaluation. Furthermore, when myocarditis is suspected, timely hemodynamic assessment and consideration of mechanical circulatory support may influence the outcomes.