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.

Essential thrombocythemia (ET) is a myeloproliferative neoplasm that is characterized by thrombocytosis. Because it is characterized by thromboembolic and hemorrhagic events, balancing the coagulation status is essential. Thromboelastography (TEG) is a point-of-care viscoelastic test that evaluates whole-blood coagulation dynamics. We herein describe the case of a patient with ischemic stroke accompanied by ET who underwent TEG. The lysis index after 30 min (LY30) was elevated when hemorrhagic transformation occurred. After augmentation with cytoreductive therapy, the platelet count and LY30 levels rapidly normalized. Our findings indicate that TEG may be therefore useful for monitoring the complicated coagulation status of ET patients.

We herein report a case of hyperglycemia in a patient with recurrent breast cancer treated with the AKT inhibitor capivasertib. Continuous glucose monitoring revealed a distinctive pattern characterized by pronounced daytime postprandial hyperglycemia and nocturnal-to-morning decline, which resolved during the drug-free intervals. Hyperglycemia was unresponsive to metformin treatment but was markedly exacerbated by intravenous glucose infusion. These findings suggest that capivasertib-induced hyperglycemia is caused by an impaired glucose uptake and dysregulated hepatic glucose output associated with AKT inhibition. Careful glycemic monitoring and individualized management are necessary in patients receiving AKT inhibitors.

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, Ltd., 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.

A prominent attentional deficit is an uncommon primary manifestation of an isolated midbrain infarction. We present the case of a 62-year-old man with an acute right midbrain infarct who presented with a marked attentional deficit, observed as repeated forgetting to flush the toilet. His classical neurological signs, including mild ataxia and dysarthria, were minor compared with his functionally impaired cognitive dysfunction. This case illustrates a potential dissociation between motor signs and cognitive impairment in patients with midbrain lesions and emphasizes the value of performing a neuropsychological assessment to identify less apparent disabilities and facilitate appropriate intervention.

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 ΔsMg, as well as the changes in parameters associated with ΔsMg.

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

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is a life-threatening respiratory illness that shares clinical similarities with autoimmune diseases, which some patients subsequently develop. We herein report a case of an older Japanese patient who presented with skin rash, relapsing progressive interstitial lung disease, and anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody seropositivity after COVID-19 infection. Although the patient was elderly, her symptoms improved with the administration of corticosteroids, tacrolimus, and intravenous cyclophosphamide, indicating that this combination may be a viable treatment option for anti-MDA5 antibody-positive pneumonia, which is a complication of COVID-19.

An infected aneurysm can be fatal; however, its early diagnosis is challenging because of the non-specificity of its symptoms. We herein report the case of a 90-year-old female patient with an infected aneurysm who presented with progressive, unilateral pleural effusion. A pleural fluid analysis revealed a mononuclear cell-predominant exudate with an elevated adenosine deaminase (ADA) level of 61.4 U/L. While these findings indicate that an infected aneurysm should be considered a possible cause of unilateral pleural effusion, the presence of elevated ADA, suggesting an unrelated condition, may lead to a misdiagnosis. Blood cultures and follow-up imaging are therefore necessary adjuncts to a comprehensive assessment of the patient's condition if an infected aneurysm is to be definitively diagnosed.

A 68-year-old man with symptoms of back and left anterior chest pain was diagnosed with non-ST-segment elevation myocardial infarction and underwent coronary angiography, which showed 99% stenosis in the diagonal artery. After administering dual antiplatelet therapy, the lesion was successfully treated with a drug-eluting stent. On the day following the procedure, he developed left upper extremity paresthesia with persistent back pain, which was diagnosed as spontaneous spinal epidural hematoma by magnetic resonance imaging. Urgent surgical decompression was performed, leading to a complete resolution of the neurological symptoms. This case describes the difficulties in making a diagnosis and the necessity of performing immediate management.

A 66-year-old man presented to our hospital following the detection of abnormal chest shadows during a previous medical checkup. Chest computed tomography revealed multiple small nodules in both lungs, and surgical biopsy was performed for the diagnosis. A histological examination of the pulmonary nodules revealed small non-caseating epithelioid cell granulomas with prominent infiltration of lymphocytes and IgG4-positive plasma cells. The patient was eventually diagnosed with pulmonary sarcoidosis, with a B-cell response similar to that of IgG4-related disease. This report provides insight into sarcoidosis with histopathological features similar to those of IgG4-related diseases.

Objective To identify background factors associated with whether residents remain at the same institution for specialty training after completing initial clinical training or choose to transfer to a different institution.

Methods We conducted a retrospective cohort study to analyze the demographic characteristics, geographic background, and recruitment interview data. Data were collected from the institutional records and recruitment interview documents obtained during the application process. A Firth-corrected logistic regression analysis was performed to identify the predictors of training continuation.

Patients or Materials We studied 261 physicians who entered the mandatory two-year initial clinical training at the Jichi Medical University, Saitama Medical Center, between fiscal years 2012 and 2021. Physicians who had graduated from Jichi Medical University (under return-service obligations) were excluded. Participants were categorized into the Continuing Training (remaining at our institution) and Other Institution (trained elsewhere) groups.

Results Among 261 participants who entered initial clinical training, 123 (47.1%) remained at our institution for specialty training. The General Medicine Open Course, which allows 28 weeks of elective rotation exclusively within our institution, was the primary independent predictor of retention. Firth-corrected logistic regression identified preference for the general medicine open course as an primary independent predictor (adjusted OR: 16.25, 95% CI: 1.78-2177; p =0.009).

Conclusion Preference for the general medicine open course was independently associated with continuing specialty training at the same institution. This finding suggests that training courses providing extensive intra-institutional exposure may enhance institutional retention. These findings may inform recruitment strategies and training program designs; however, validation through larger multi-institutional studies is required.

Turner syndrome is well defined as a sex chromosomal disorder that occurs when one of the two X chromosomes is missing or incomplete. The typical clinical features of Turner syndrome have been well defined, and some lesions of the Turner-associated phenotype have been identified. We herein report a case of Turner syndrome caused by a rare karyotype with translocation of the short arm of chromosome 7 to the X chromosome. The information obtained in this case will be useful for evaluating Turner syndrome in the future.

Objective This study assessed the effectiveness of the recombinant zoster vaccine (RZV) in preventing herpes zoster (HZ) in rheumatoid arthritis (RA) patients treated with Janus kinase (JAK) inhibitors.

Methods This was a retrospective analysis. The patients were categorized into vaccinated (n =74) and unvaccinated (n =120) groups. HZ incidence was compared using the Kaplan-Meier method, and vaccine effectiveness was estimated using inverse probability of treatment weighting (IPTW) to adjust for baseline confounding factors.

Patients 194 Japanese RA patients were analyzed treated with JAK inhibitors at our institution from January 2020 to September 2024.

Results The observation spanned 124.4 person-years in the vaccinated group and 256.2 in the unvaccinated group. HZ occurred in six vaccinated cases (4.8 per 100 person-years) versus 20 unvaccinated cases (7.8 per 100 person-years) (p =0.32). The overall efficacy of the vaccine was 59.1%. HZ incidence varied by JAK inhibitor: baricitinib (5.5 vs 9.9), upadacitinib (12.4 vs 6.2), and filgotinib (0.0 vs 1.6) per 100 person-years. Vaccinated patients who developed HZ had significantly lower lymphocyte counts and higher SDAI and CDAI scores.

Conclusion Although not statistically significant, RZV vaccination tended to reduce the incidence of HZ in Japanese RA patients receiving JAK inhibitors. The effectiveness varied according to the type of JAK inhibitor, with lower lymphocyte counts and higher disease activity, and it may predict insufficient protection.

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 CT 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.

Mycobacterium mageritense is a species of rapidly growing mycobacteria (RGM) found in environmental sources, possibly causing skin, soft tissue, and intravascular device infections. We encountered a case of prostatic abscess caused by M. mageritense that developed three months after transurethral resection of a bladder tumor. The patient was treated with antibiotics and underwent radical cystectomy. Prostatic abscesses due to RGM are rare, but may sometimes be overlooked. Mycobacterial cultures may be helpful in the diagnosis of culture-negative prostatic abscesses following these procedures.

Objective Vascular calcification is associated with poor cardiovascular outcomes. However, the significance of calcification-related biomarkers in patients without advanced chronic kidney disease (CKD) remains unclear.

Methods We prospectively enrolled 68 patients who underwent coronary computed tomography angiography followed by coronary angiography. This study assessed serum FGF-23, osteoprotegerin (OPG), and fetuin-A levels along with the calcification of the coronary arteries, aortic valve, aortic arch, and abdominal aorta. Patients on maintenance dialysis were excluded, and the renal function was predominantly preserved (median eGFR 67.9 mL/min/1.73 m²). Associations were examined using Spearman's ρ, and the discrimination of severe coronary artery calcification (CAC) (Agatston ≥400) was evaluated using an ROC analysis.

Results CAC was correlated with FGF-23 (ρ =0.379, p =0.002), but not with fetuin-A or OPG. FGF-23 was also associated with the aortic arch (ρ =0.284, p =0.019), abdominal aortic calcification (ρ =0.311, p =0.010), and left ventricular mass index (ρ =0.425, p <0.001). For severe CAC, OPG showed the highest, albeit modest, discrimination (area under the ROC curve 0.69, 95% confidence interval 0.56-0.82; Youden cutoff 9.47), but it was not independently associated after adjusting for age. All biomarkers showed a weak association with aortic valve calcification.

Conclusion In patients without advanced CKD, FGF-23 is associated with systemic vascular calcification and left ventricular remodeling, whereas OPG provides only a modest unadjusted discrimination for severe CAC and does not add to age. These findings suggest a limited, context-dependent role for these biomarkers, and underscore the need for larger, externally validated studies.

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

Methods and Patients 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-naive 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.

Cancer-associated stroke (CAS) presents significant challenges regarding secondary prevention. A 48-year-old woman with pancreatic cancer experienced two episodes of large-vessel occlusion stroke was treated by mechanical thrombectomy. Subcutaneous heparin was discontinued owing to skin reactions, and recurrence occurred despite the use of a direct oral anticoagulant. As an alternative, intravenous heparin was initiated at home via a chemotherapy port, using a portable infusion pump. This individualized approach was implemented without any major complications, and it may represent a practical option for patients with CAS who are either intolerant or refractory to conventional therapies.

The use of the Freezor Xtra catheter (Medtronic, Minneapolis, MN, USA) is preferred for atrioventricular nodal reentrant tachycardia owing to its low AV block risk. Therefore, use of this catheter is occasionally applied to para-Hisian ventricular arrhythmia (VA). However, the tips for catheter use in intractable cases remain challenging. This report consists of two cases of drug-resistant VAs originating from para-His. Case 1 involved a 76-year-old man who was treated VA using the reverse bending catheter technique. Case 2 involved 59-year-old man with VA who was treated at the earliest left ventricular activation site using a transseptal approach. These cases highlight the practical strategies for challenging para-His VA cases.

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.

We report a rare case of giant cell arteritis (GCA) initially presenting as ischemic stroke in the perforating branch territory. An 81-year-old woman presented with dysarthria and was diagnosed with a right midbrain and pontine infarction. Six months later, the patient developed recurrent dysarthria and left hemiparesis. Magnetic resonance imaging (MRI) revealed a new right lenticulostriate infarct, and MRA showed rapidly progressive intracranial stenosis. Vessel wall MRI demonstrated concentric enhancement in the intracranial and extracranial arteries. A temporal artery biopsy confirmed the presence of GCA. This case highlights the diagnostic value of vessel wall imaging for detecting intracranial involvement in GCA.

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.

Recent advances in drug development have revolutionized the field of oncology, leading to the development of novel therapeutic strategies. Among them, bispecific antibodies (BsAbs) targeting CD3 and tumor antigens have shown significant efficacy in relapsed or refractory multiple myeloma (RRMM). In triple-class exposed RRMM, where the median survival is less than 2 years, BsAbs redirect T cells toward targets such as BCMA and GPRC5D, achieving response rates of approximately 60%-70% with durable efficacy, resulting in regulatory approvals. Adverse events, such as cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and infections, are generally manageable. However, reduced efficacy in patients with high tumor burden, antigen loss, and T-cell exhaustion remains a challenge. Ongoing research is focused on optimizing dosing, combination strategies, and earlier use. BsAbs offer a promising therapeutic option with the potential to reshape treatment paradigms and improve long-term outcomes in multiple myeloma patients.

Overwhelming post-splenectomy infection (OPSI) is a life-threatening condition typically caused by Streptococcus pneumoniae. Necrotizing fasciitis (NF) 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.

A 44-year-old man with spinal and bulbar muscular atrophy (SBMA) and an anterior mediastinal tumor presented with ptosis and diplopia with diurnal variation. Dysarthria, dysphagia, and limb weakness deteriorated acutely, and developed respiratory failure. Repetitive nerve stimulation resulted in a decremental response. Ice pack and edrophonium tests were positive. Myasthenia gravis (MG) was diagnosed based on the presence of anti-acetylcholine receptor (AChR) antibodies. Immunotherapy improved the myasthenic symptoms. Although a few cases of SBMA exhibiting myasthenic symptoms have been reported, none of these patients had anti-AChR antibodies. This is the first report of seropositive MG with comorbid SBMA.

Granular cell tumors and schwannomas rarely occur in cystic ducts. We herein report a case of a hybrid tumor consisting of a cystic duct-originating granular cell tumor and schwannoma. A 48-year-old woman was referred to our hospital with the chief complaint of occasional postprandial abdominal pain after an enlarged gallbladder was found on ultrasonography. The cause was identified as a mass measuring approximately 7 mm in diameter in the cystic duct, and the patient underwent extrahepatic cholangiectomy. An examination of the surgical specimen revealed that the mass originated from the cystic duct and narrowed the duct lumen. Histopathologically, both granular cell tumors and schwannoma components were detected. To our knowledge, this is the first report of a hybrid peripheral nerve sheath tumor with a mixture of granuloma cell tumors and schwannomas.

Sporadic late-onset nemaline myopathy (SLONM) is a rare, acquired myopathy that is frequently associated with monoclonal gammopathy, most commonly monoclonal gammopathy of undetermined significance (MGUS). However, its association with overt multiple myeloma (MM) has been rarely reported. We present a case of SLONM associated with MM in which chemotherapy targeting the underlying MM led to mild-to-moderate improvement in muscle symptoms. This case underscores the potential pathogenic role of MM in SLONM and highlights the importance of treating underlying hematologic malignancies.

A 74-year-old woman presented with a fever and profuse vomiting. Contrast-enhanced computed tomography (CT) showed a marked dilation of the stomach and proximal duodenum and a retroperitoneal abscess extending from the right ureter due to inflammatory spread. She was treated conservatively with nasogastric decompression and intravenous antibiotics, thus leading to a gradual resolution of both the obstruction and the abscess. This case highlights a rare but important complication of a urinary tract infection, emphasizing that extrinsic inflammatory etiologies should be considered in the differential diagnosis of duodenal obstruction, and that timely recognition may allow for successful conservative management without the need to perform any invasive procedures.

Hydrogel spacers are commonly used to reduce rectal toxicity during radiation therapy for prostate cancer. Although generally safe, rare, serious complications may occur. We report the case of a man with diabetes and renal failure who developed a refractory rectal ulcer and fistula five months after spacer placement, followed by Fournier's gangrene. The patient recovered following surgical drainage and antibiotic therapy. This is the first reported case of Fournier's gangrene following hydrogel spacer insertion. Spacer-related rectal wall infiltration might have contributed to this finding. Clinicians should recognize such adverse events and consider early intervention in high-risk patients presenting with hematochezia or perineal symptoms.

A 49-year-old man with prior DeBakey IIIb dissections underwent preoperative spinal MRI for lumbar stenosis, which incidentally showed lumbosacral dural ectasia and bilateral pedicle thinning. Orthopedic review and cross-disciplinary discussion prompted reconsideration of Marfan syndrome (MFS). Under the revised Ghent criteria, the patient did not meet the diagnostic criteria despite a high systemic score (11). Targeted testing identified heterozygous PMEPA1 c.624dup, p. (Ser209Glnfs*3), supporting Loeys-Dietz syndrome with skeletally predominant features. This case illustrates that spine-MRI red flags should prompt Ghent-based re-examination and genetic referral when aortic-root features are absent, and genetic confirmation should guide cascade testing and risk-adapted surveillance of relatives.

A 44-year-old Japanese woman presented with low-density lipoprotein cholesterol (LDL-C) 214 mg/dL and lipoprotein(a) 65 mg/dL. Targeted next-generation sequencing identified heterozygous proprotein convertase subtilisin/kexin type 9 (PCSK9) (p.Glu32Lys) and ATP-binding cassette subfamily G member 8 (ABCG8) (p.Ile419Asn) variants. Despite lifelong untreated hypercholesterolemia, she only exhibited Achilles tendon thickening, without any other atherosclerotic signs. Combination therapy with rosuvastatin (5 mg) and ezetimibe (10 mg) lowered her LDL-C levels to approximately 70 mg/dL. This paradoxical mild atherosclerosis, despite multiple genetic and lipoprotein risks, highlights the heterogeneity of Familial Hypercholesterolemia and the utility of genotype-guided risk stratification.

Background There are no comparative studies on provoked coronary microvascular spasm (CMS) in patients undergoing both acetylcholine (ACh) and ergonovine (EM) vasoreactivity testing.

Objectives We investigated the incidence of provoked CMS in patients with ischemia with nonobstructive coronary artery disease (INOCA) undergoing ACh and EM vasoreactivity testing.

Methods We recruited 494 INOCA patients who underwent both ACh and EM vasoreactivity testing. ACh was injected at incremental doses of 20/50/100/200 μg into the left coronary artery (LCA) and 20/50/80 μg into the right coronary artery (RCA), whereas 40 μg of EM was administered into the RCA and 64 μg into the LCA. Positive CMS was defined as <75% transient coronary constriction, accompanied by typical chest symptoms or ischemic ECG changes.

Results Among the 494 patients, CMS was observed in 23 (4.7%) patients. Eighteen patients had CMS alone, and 5 patients had coexisting epicardial spasm. The ACh test alone, EM test alone, and both tests provoked CMSs in 12 patients, 7 patients, and 4 patients, respectively. There were no marked differences in incidence between ACh- and EM-induced CMS (70% vs. 48%, p=0.2307).

Conclusions Differences were observed between ACh-induced CMS and EM-induced CMS. The complementary use of vasoreactivity testing is essential for accurately documenting the presence of CMS in real-world settings.

A 67-year-old man was diagnosed with Hashimoto's thyroiditis, and replacement therapy with levothyroxine was initiated. Ten years later, although the patient was euthyroid, ultrasonography showed an increase in goiter size and a significant decrease in overall echogenicity with scattered high-echo areas. Computed tomography revealed diffuse low-density areas with no contrast effect in the thyroid parenchyma and partial high-density areas, indicating possible malignancy. However, a core needle biopsy revealed an amyloid light-chain (AL) κ-type amyloid goiter. Because serum immunoprecipitation electrophoresis showed IgG κ-type M-protein, the diagnosis was secondary amyloidosis. It is important to consider amyloid goiter with imaging findings, as in this case.

Objectives Since andexanet alfa was approved in May 2022 in Japan, improvement in clinical outcomes of patients with intracranial hemorrhage while on factor Xa inhibitors (FXaIs) is expected. To assess real-world outcomes before approval, this study investigated the clinical outcomes in Japan prior to 2022.

Methods Patients who developed intracerebral hemorrhage (ICH) or non-traumatic subarachnoid hemorrhage (SAH) and were admitted within 24 h of their last known well time or onset of symptoms between January 2016 and December 2021 were included. Data were obtained from the Japan Stroke Data Bank, a nationwide multicenter prospective registry. The outcomes were in-hospital mortality and favorable outcomes (modified Rankin Scale score of 0-2 at discharge).

Results A total of 859 patients (rivaroxaban, n=227; apixaban, n=355; edoxaban, n=277) with ICH (ICH: n=822, age 79±9 years, 38.6% female; SAH: n=37, age 79±10, 75.7% female) were investigated. On admission, the median National Institutes of Health Stroke Scale (NIHSS) score in ICH patients was 13 [interquartile range (IQR): 6-24], and the median Glasgow Coma Scale score in patients with SAH was 11 [IQR: 6-14]. During the in-hospital period (20 [IQR: 11-37] days), 167 patients with ICH (20.3%) and 14 patients with SAH (37.8%) died in hospital; 135 patients with ICH (16.4%) and 5 patients with SAH (13.5%) achieved a favorable outcome.

Conclusion This study presents the clinical outcomes prior to the approval of andexanet alfa. Further studies are needed to evaluate post-approval outcome changes.

The effectiveness of selpercatinib against RET-fusion-positive non-small cell lung cancer (NSCLC) in geriatric patients is underreported. We report the case of an 84-year-old woman in whom reduced-dose selpercatinib elicited a significant tumor response in KIF5B-RET fusion-positive NSCLC. However, she developed acalculous cholecystitis, which led to the discontinuation of the drug. This is the first reported case of selpercatinib-induced acalculous cholecystitis in a patient. The report highlighted the potential efficacy of selpercatinib in elderly patients while underscoring the risk of severe adverse events and emphasizing monitoring and personalized dose management.

Background The global prevalence of multiple sclerosis (MS) is increasing worldwide. Although many disease-modifying therapies (DMTs) have been approved, they can cause serious adverse events, including infections. Dimethyl fumarate (DMF), an immunomodulator, has a favorable safety profile. In this era of personalized therapy, it is important to select an appropriate DMT for individual patients. This study evaluated DMF treatment outcomes in Japanese patients with MS.

Methods The medical records of Japanese patients with MS treated with DMF at a single institution between January 6, 2013, and October 31, 2022, were reviewed retrospectively. The reasons for discontinuation of DMF, switching from other DMTs to DMF, transition of DMF to other medications, absolute lymphocyte count, disease activity assessment, comparison of DMF continuation versus discontinuation, and factors associated with the annualized relapse rate during DMF use were assessed.

Results Of the 116 DMF-treated patients, DMF treatment was continued to prevent relapse recurrence in 54.7% of RRMS (n=86) and 23.3% of SPMS (n=30) patients. The main reasons for not continuing DMF treatment included failure to prevent relapse or disease progression (63% of patients who did not continue DMF). A lower annual recurrence rate prior to DMF initiation, lower Expanded Disability Status Scale score, shorter duration from disease onset to DMF initiation, fewer relapse recurrences during DMF therapy, and diagnosis of RRMS were associated with DMF continuation.

Conclusion Continuous monitoring is essential after initiating DMF treatment because patients may require transition to other therapies. Overall, 47% of the MS patients were effectively managed with DMF, with favorable outcomes observed in 54.7% of the RRMS patients.

Two days after eating beef steak grilled rare, a 28-year-old man developed a fever, abdominal pain, and diarrhea. The diarrhea resolved after 5 days of ciprofloxacin treatment (200 mg). Stool cultures obtained at the time of the onset were subsequently confirmed as enterotoxigenic Escherichia coli type O6. However, the renal dysfunction worsened, and the patient developed proteinuria and urinary occult blood. A kidney biopsy revealed necrotizing glomerulonephritis in the majority of glomeruli. An enzyme-linked immunosorbent assay was negative for myeloperoxidase/proteinase 3 anti-neutrophil cytoplasmic antibody (ANCA), but indirect immunofluorescence (IIF) was positive for cytoplasmic ANCA (C-ANCA). This case suggests a relationship between necrotizing glomerulonephritis and IIF-positive C-ANCAs.

Objective It is important to identify the causative parathyroid gland before parathyroidectomy in patients with primary hyperparathyroidism; however, there are some cases of preoperative localization failure. This study assessed the characteristics of patients with failure to localize the causative parathyroid gland.

Methods and Patients This study included 114 patients with primary hyperparathyroidism. Physical and biochemical indices were measured, and neck ultrasonography, technetium-99m methoxy isobutyl isonitrile scintigraphy, and magnetic resonance imaging were performed. Localization of the causative gland was confirmed by consensus among multiple physicians.

Results The causative parathyroid glands were localized in 83 patients (73%) with primary hyperparathyroidism. Successful localization was defined as cases in which preoperative imaging accurately identified the causative parathyroid gland, and localization failure included cases with no preoperative identification or those requiring additional resections due to incorrect localization. Most preoperative localization diagnoses in the patients who underwent parathyroidectomy were confirmed to be accurate. Patients with localization failure were significantly older and exhibited lower levels of serum chloride, calcium, intact parathyroid hormone, and urinary calcium values, along with higher serum phosphorus levels, greater phosphate reabsorption, and a smaller tumor size than those with successful localization. Even after adjusting for the age, sex, and body mass index, intact parathyroid hormone levels were significantly associated with successful localization.

Conclusion A relatively old age; low levels of serum chloride, calcium, intact parathyroid hormone, and urinary calcium; high levels of serum phosphorus; phosphate reabsorption; and a relatively small tumor size were associated with localization failure of the causative parathyroid gland.

Objective To evaluate whether a simple biomarker can identify possible sarcopenia (PS) in a community-dwelling elderly population.

Methods This study included 289 individuals ≥ 65 years of age who underwent medical examinations in Sobetsu in 2017. The validation cohort consisted of 183 individuals ≥ 65 years of age who were surveyed in the same town in 2018, 2019, 2022, and 2023, without participating in the 2017 survey. The predictive factors for PS were identified, and a simple scoring system was developed.

Results The mean ages of the 2017 and validation cohorts were 74 years and 72 years, respectively. The prevalence of PS did not differ between the 2017 and validation cohorts, with rates of 31.5% and 32.8%, respectively. A univariate logistic regression analysis, using the presence of PS as the dependent variable, identified age [odds ratio (OR) 1.13], anemia (OR 4.54), and hemoglobin (OR 0.63) as significant factors (p <0.001). A multivariate logistic regression model, adjusted for age, BMI, and hemoglobin level and selected based on the lowest AIC, achieved an AUC of 0.747 for predicting PS. External validation of this model yielded an AUC of 0.733. A simplified prediction score, derived from cutoffs for age, BMI, and hemoglobin, demonstrated an AUC of 0.711 for PS prediction in the initial cohort, with an AUC of 0.658 in the external validation cohort.

Conclusion A simple score based on age, BMI, and hemoglobin level effectively estimated PS in a community-dwelling elderly population, offering a practical and accessible tool for screening.

An impaired intestinal barrier exposes the microbiota to gut immune cells, triggering cytokine responses that cause Crohn's disease (CD). Barrier dysfunction is a prerequisite for CD development. However, the effects of biological therapies on barrier integrity remain poorly understood. We aimed to present a case of CD refractory to adalimumab and risankizumab. Treatment with infliximab improved refractory ulcers, and this effect was associated with alterations in the mucosal mRNA expression of claudins, cell-cell adhesion molecules that contribute to the maintenance of barrier integrity. These findings suggested that infliximab induces CD remission by regulating the expression of claudin.

A 69-year-old man initially developed cognitive impairment followed by nonfluent aphasia and left hemiparesis five months later. Initial N-isopropyl-p-[¹²³I] iodoamphetamine (¹²³I-IMP) single-photon emission computed tomography (SPECT) revealed increased regional cerebral blood flow (rCBF) in a broad area of the right cerebral cortex, including the central sulcus, as well as in the left frontal lobe. Follow-up SPECT demonstrated a decreased rCBF in the right hemisphere. The patient was diagnosed with anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis. In this case, disease progression was monitored using ¹²³I-IMP SPECT, suggesting that rCBF alterations in AMPAR encephalitis may provide insight into the underlying pathophysiology.

Primary gastric alveolar rhabdomyosarcoma (RMS) is an extremely rare condition. We report a case of a 32-year-old man who presented with abdominal distension and anorexia. Imaging revealed a gastric mass with peritoneal dissemination and vertebral metastasis. Endoscopy revealed a large, ulcerative lesion. Histopathology revealed small round cells in an alveolar pattern that were positive for desmin and myogenin. Despite the initiation of multimodal therapy, the patient developed septic shock and died 10 days after treatment. This case highlights the aggressive nature of primary gastric alveolar RMS and emphasizes the importance of integrated diagnostic approaches, including histopathological, immunohistochemical, and molecular analyses, for its accurate diagnosis and appropriate management.

Disseminated mucormycosis is a fatal infection commonly observed in patients with prolonged neutropenia, such as those undergoing treatment for hematological malignancies or post-transplantation. This report describes a case of malignant lymphoma in a patient with no history of cytotoxic chemotherapy. The patient died early, and disseminated mucormycosis was identified during an autopsy. Notably, no imaging findings were suggestive of mucormycosis, which complicated the diagnosis. Given that both mucormycosis and malignant lymphoma were suspected from the initial presentation, it is important to consider mucormycosis as a potential differential diagnosis in patients with altered consciousness.