Background: Burnout during residency is common and is associated with adverse outcomes for clinicians and patients; however, the comparative efficacy of intervention approaches remains unclear. We aimed to compare the efficacy of different categories of interventions aimed at reducing burnout among physician residents.

Methods: We conducted a systematic review of randomized controlled trials (RCTs) in physician residents (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42025610352). Searches were conducted from February 19 to 26, 2025 in PubMed, Cochrane CENTRAL, PsycINFO, Web of Science, and Ichushi-Web.

Interventions were classified into six categories: coaching, reflective intervention, intensive care unit short shift schedule, mind-body intervention, skills-based stress management, and information provision. Outcomes were emotional exhaustion (EE), depersonalization (DP), reduced efficacy (RE), and global burnout (GB). We performed a Bayesian random-effects network meta-analysis and reported standardized mean differences (SMDs) with 95% credible intervals (CrI); negative SMD values indicate improvement. Interventions were ranked using the surface under the cumulative ranking curve (SUCRA). Uncertainty was assessed using posterior effect estimates with 95% CrI and ranking probabilities. Certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) summary of findings tables.

Results: A total of 20 RCTs (n = 2,616) were included; risk of bias was mostly rated as some concerns (5% low, 60% some concerns, and 35% high risk). Effects were generally small, and estimates were imprecise. By SUCRA, reflective interventions ranked highest for EE and DP (EE: SMD −0.515 [95% CrI, −1.068 to 0.041]; DP: SMD −0.432 [−0.988 to 0.133]), whereas coaching ranked highest for RE and GB (RE: SMD −0.142 [−0.538 to 0.262]; GB: SMD −0.451 [−1.180 to 0.195]). Certainty was predominantly low to very low.

Conclusions: The comparative superiority of any single intervention category remains unclear. Reflective interventions, which support guided reflection on clinical work, and coaching showed comparatively favorable signals for some burnout domains, but estimates were imprecise and of low certainty. Findings may inform cautious prioritization and highlight the need for pragmatic, adequately powered trials.

Artificial intelligence (AI) has established itself as a key tool in the development of precision medicine, offering opportunities to improve risk prediction, early diagnosis, and personalized treatments for obesity. However, its implementation poses ethical challenges that cannot be ignored. The use of sensitive data such as genetic, metabolic, and behavioral information raises questions about privacy, security, and informed consent. Furthermore, the existence of algorithmic biases can reproduce inequities and limit the validity of models in diverse populations, particularly in low-resource settings.

Another critical aspect is the lack of transparency in many AI systems, whose operation as “black boxes” makes it difficult to interpret their recommendations and weakens trust between professionals and patients. Legal accountability for errors in clinical decision-making, limited accessibility of high-cost technologies, and the imperative to respect patient autonomy and cultural context highlight the urgency of establishing a clear and enforceable ethical framework.

This narrative review analyzes the main ethical dilemmas associated with the use of AI in precision medicine for obesity, highlighting challenges related to equity, transparency, social justice, and clinical accountability. The need for responsible technological development is raised, ensuring respect for patients' rights and promoting equitable use of these innovative tools in addressing one of the most complex and prevalent diseases worldwide.

Background: Anticholinergic burden has been linked to adverse geriatric outcomes. However, quantitative evidence regarding its associations with skeletal muscle indices and functional outcomes remains limited, particularly for muscle quality. We conducted a scoping review to map the current evidence and identify research gaps.

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, we searched PubMed, Google Scholar, and CiNii from inception to January 23, 2026 for English or Japanese primary observational or interventional studies that quantitatively assessed anticholinergic burden using validated or previously published scales/classifications and at least one outcome related to skeletal muscle (mass, quality, or strength), physical function, or activities of daily living (ADL)/instrumental ADL (IADL). Eligible populations were older adults (aged ≥60 years, or studies with a mean/median age ≥60 years, or studies reporting a predefined older-adult subgroup). Case reports, nonhuman studies, reviews, and editorials were excluded. Two reviewers independently screened records and charted data using a standardized form.

Results: Of 231 identified records, 18 studies met the inclusion criteria. Two studies assessed skeletal muscle mass using bioelectrical impedance analysis, reporting appendicular skeletal muscle mass and skeletal muscle mass index; no study directly assessed skeletal muscle quality. Most studies evaluated physical function and/or ADL/IADL. The majority reported that higher anticholinergic burden was associated with poorer physical function and/or greater dependence in ADL/IADL, although some findings were subgroup-specific (e.g., restricted to older strata) or null for certain measures (e.g., grip strength and some Timed Up and Go analyses). Measures of anticholinergic burden and outcome ascertainment varied substantially across studies.

Conclusions: Quantitative assessment of anticholinergic burden may serve as an auxiliary indicator to prompt medication review in older adults; however, the available evidence is associative and subject to residual confounding (including confounding by indication and polypharmacy). In contrast, evidence directly linking anticholinergic burden to skeletal muscle indices – especially muscle quality – remains scarce. Studies incorporating direct skeletal muscle assessments are needed to better characterize these associations and explore potential mechanisms, including indirect pathways involving the central nervous system, mood, and activity.

Ripple activity is defined as a high-frequency synchronous neural activity that has emerged as an important biomarker of epilepsy, both in research and clinical practice. In intracranial electroencephalography, ripple-band activity is closely linked to epileptogenicity and has been investigated as a marker to guide localization of epileptogenic tissue and predict surgical outcomes. Simultaneously, in the hippocampus, ripple activity additionally includes physiological sharp-wave ripples (SWRs), which play essential roles in memory consolidation, retrieval, and the selection of experiences for long-term storage. This overlap gives hippocampal ripple activity dual clinical significance: it may indicate pathological synchrony related to epilepsy, and it can also indicate the physiological processes that support memory and other higher cognitive functions. This review summarizes the current knowledge regarding the dual significance of hippocampal ripple activity in epilepsy. First, the pathological relevance of high-frequency oscillations as biomarkers of epileptogenicity and the physiological role of SWRs in hippocampal-cortical information processing are outlined. Subsequently, the methodological challenges involved in distinguishing pathological ripples from physiological SWRs in human intracranial recordings are discussed. Recent advances in consensus-based criteria, spatiotemporal analyses, and machine learning–based detection methods are further reviewed. Mechanistic frameworks further indicate that ripples reflect a shared synchrony-generating substrate, whose meaning depends on the network state, behavioral context, and spatial relation to the epileptogenic focus. Finally, ripple activity could be interpreted not only as a local hippocampal event but also as a marker of hippocampo–neocortical network state, with potential implications for epileptogenicity assessment, surgical planning, and function-preserving treatment strategies. Understanding the dual role of the hippocampal ripple activity may provide a basis for more precise epilepsy therapies that balance seizure control and memory preservation.

Introduction: Generative artificial intelligence (gAI), particularly large language models such as ChatGPT, is rapidly transforming various sectors, including medical education. Despite increasing interest, few studies have investigated how gAI is actually used in medical education settings, especially in Japan. This study aimed to assess the current use of gAI among medical students and faculty members, and to compare gAI usage patterns and attitudes between these two groups.

Methods: A cross-sectional survey was conducted from April to May 2025 at the Oita University Faculty of Medicine. A total of 1,017 students and 470 faculty members from the School of Medicine, School of Nursing, and Department of Advanced Medical Sciences were invited to complete an anonymous online questionnaire. The survey covered gAI usage experience, purposes of use, and attitudes toward gAI in academic contexts.

Results: The response rates were 40% for students (402/1,017) and 74% for faculty members (350/470). Most students (82.1%) and faculty (73.4%) had prior experience using gAI tools, primarily for report writing, lecture preparation, and information retrieval, with students showing a higher rate of gAI usage experience than faculty (p < 0.05). While 92.8% of students and 86.5% of faculty supported gAI use under certain conditions, 73.4% of faculty members reported major concerns, including ethical risks and the risk of personal information leakage. In the faculty survey, younger faculty members, and those with gAI usage experience were also significantly more likely to approve the introduction of gAI into medical education (p < 0.05).

Conclusions: gAI is widely accepted and used in medical education. However, ethical guidelines, digital literacy education, and thoughtful integration strategies are essential to ensure its responsible use.

Introduction: The 2011 Fukushima nuclear disaster following the Great East Japan Earthquake did not cause significant physical health effects, but long-term mental distress persists, partly driven by radiation risk perception. Women, particularly those undergoing breast cancer screening in affected areas, may experience heightened breast cancer anxiety and mental distress. The interrelationships among radiation risk perception, breast cancer anxiety, and mental distress remain unclear. This study aimed to elucidate these associations among women in Minamisoma, one of the municipalities most severely affected by the disaster.

Methods: A self-administered questionnaire survey was conducted among 479 women who attended breast cancer screening at two core breast cancer care centers located more than 20 km north of the Fukushima Daiichi Nuclear Power Plant. This cross-sectional study assessed breast cancer anxiety, risk perception of breast cancer and radiation exposure, and mental distress. Mental distress was evaluated using the Kessler Psychological Distress Scale (K6) scale, with scores ≥5 considered significant. Descriptive analyses and regression models were constructed to explore the relationships among these three outcomes.

Results: Among participants, 47.4% (227/479) reported moderate mental distress. Higher odds of general breast cancer anxiety were observed among those who perceived a high likelihood of radiation-induced breast cancer (odds ratio [OR], 2.99; 95% confidence interval [CI]: 1.76-5.08; p < 0.001). Higher odds of mental distress were also associated with belief in radiation-induced breast cancer (OR, 1.76; 95% CI: 1.19-2.59; p = 0.004). However, breast cancer anxiety itself was not significantly associated with mental distress (OR, 1.29; 95% CI: 0.83-2.01).

Conclusions: Approximately half of the women experienced moderate mental distress five years after the disaster. The results suggest that mental distress is heightened by radiation risk perception and underlying general health concerns, rather than specific factors such as breast cancer anxiety.

Introduction: To develop a real-time artificial intelligence (AI) system using a convolutional neural network for the assessment of infant head control (good or poor) during the traction response.

Methods: Infants aged 3-6 months who received community-based group health checkups and whose guardians provided informed consent were enrolled in this study. Videos were recorded during the pull-to-sit test conducted by a pediatrician. The collected videos were divided into training and test datasets. Training data were extracted as image frames and labeled according to the pediatrician's judgment. After supervised machine learning, the AI system was evaluated using the test dataset, and the sensitivity, specificity, and detection rate were calculated.

Results: Altogether, 184 videos were collected and divided into the training (n = 110) and test (n = 74) datasets. The training and test datasets included 103 (93.6%) and 64 (86.5%) videos, respectively, showing infants with good head control. After machine learning, the screening AI system had sensitivity and specificity (95% confidence interval) values of 50.0% (18.7%-81.3%) and 98.4% (91.6%-100%), respectively. The detection rate was 100%.

Conclusions: The proposed AI-based assessment system was able to identify good head control with high specificity during the pull-to-sit test but demonstrated limited sensitivity for detecting poor head control, suggesting a supportive rather than a standalone clinical role.

Introduction: Self-reported health is a robust indicator linked to mortality, morbidity, and health-related quality of life. Nonrestorative sleep―subjective unrefreshing sleep―is increasingly reported in middle-aged adults and is related to cardiometabolic and mental conditions, yet its relationship with perceived health in this group is underexplored. This study investigated the associations between nonrestorative sleep and poor self-reported physical and mental health among middle-aged adults in Japan.

Methods: A cross-sectional postal survey was conducted in 2020 using a self-administered questionnaire among 33,902 community residents aged 40-64 years in five cities of Osaka Prefecture, Japan. After excluding missing data, 11,086 participants remained for analysis. Physical and mental health were assessed with standardized rating items, dichotomized into “very good/good/average” versus “poor/very poor.” Nonrestorative sleep was defined by the question, “Do you feel refreshed after a night's sleep?” with “no” indicating nonrestorative sleep.

Results: Among the study cohort, nonrestorative sleep was associated with increased risk ratios (RRs) for poor physical health (adjusted RR: 2.13; 95% confidence interval [CI]: 1.97-2.29) and poor mental health (adjusted RR: 2.21; 95% CI: 2.06-2.36). For participants without a history of present illness, the adjusted RRs were 2.55 (95% CI: 2.11-3.07) for poor physical health and 2.51 (95% CI: 2.18-2.89) for poor mental health. All models were adjusted for sociodemographic, behavioral, and health-related factors. Nonrestorative sleep consistently showed the highest RRs in the primary multivariable models.

Conclusions: This large-scale study demonstrates that nonrestorative sleep is strongly associated with poor self-reported physical and mental health in middle-aged adults.

Introduction: Occupational physicians (OPs) in Japan share a common medical foundation with other clinicians, but they primarily work in advisory and preventive settings. How this medical foundation is recontextualized and operationalized as clinical competence in everyday occupational practice remains underexplored. Clarifying this process may help to better understand how biomedical reasoning is applied to workplace decision-making beyond diagnosis and treatment.

Methods: We conducted a qualitative study using reflexive thematic analysis (RTA) of semi-structured interviews with 12 OPs in Japan. Braun and Clarke's six-phase framework guided iterative coding, theme development, and interpretive synthesis. Credibility was enhanced through reflexive, iterative analytic procedures.

Results: Analysis identified three interrelated practice domains: (1) statutory occupational health duties, including fitness-for-work and return-to-work judgment, (2) advice and negotiation with stakeholders, and (3) individualized support and follow-up, and five cross-cutting processes: role adaptation, reinterpretation of prior clinical expertise, responsiveness to legal and organizational contexts, collaborative negotiation, and reflective learning. Across these domains, OPs selectively mobilized clinical knowledge to address often undifferentiated health concerns, translating biomedical reasoning into context-sensitive judgments, advice, and coordination under workplace constraints. Despite substantial variability in how clinical competence was understood, recurring operational patterns were observed across participants' accounts.

Conclusions: Clinical competence in occupational medicine was not defined by fixed standards or uniformly shared expectations. Nevertheless, practice remained operationally coherent through recurring patterns across three domains and five processes, through which OPs selectively mobilized and translated clinical reasoning in response to role-related, organizational, and regulatory demands. Rather than prescribing a single competence standard, these findings provide an empirical basis for understanding how general medical training is adapted for preventive and advisory practice in occupational health, and may inform reflective, case-based learning in heterogeneous training settings.

Introduction: This study investigated the association of maternal nationality with stillbirth and infant mortality in Japan.

Methods: The Vital Statistics data in Japan from 2010 to 2023 were used, and singleton births born from 2010 to 2022 were used in the analysis of stillbirth and infant mortality. The maternal nationality consisted of Japan, Korea, China, the Philippines, Thailand, the United States (US), Brazil, Peru, and other countries in the analysis. Stillbirth and infant mortality rates were calculated by maternal nationalities. In addition, modified Poisson regression models were used to investigate the associations between the outcomes and maternal nationality, and residential area, parity, maternal age, marital status, and year of birth were adjusted.

Results: Data on 12,287,030 live births and 33,968 stillbirths were analyzed. As a result, the stillbirth rate for American mothers was the highest, and that of “other countries” was the second highest. In addition, the infant mortality rate of American mothers was also the highest. The multivariate regression analysis revealed that mothers from the US and “other countries” had a significantly higher risk of stillbirth than Japanese mothers and mothers from the US had a significantly higher risk of infant mortality than Japanese mothers.

Conclusions: It was suggested that support before and after childbirth is particularly necessary for American mothers in Japan.

Introduction: Universal health coverage has been cited as a critical factor in Japan's success in limiting mortality due to coronavirus disease 2019 (COVID-19). It is unclear if this success extended to non-Japanese residents, especially prior to roll out of COVID vaccines. Non-Japanese residents represent a growing minority of Japan's population, so this study aimed to assess any disparities in COVID-19 mortality between Japanese nationals and non-Japanese residents.

Methods: In this natural experiment, mortality due to COVID-19 was derived from death certificate data (2020-2021) registered by the Ministry of Health, Labour and Welfare (MHLW). Mortality rates were compared between Japanese nationals and non-Japanese residents, and then mortality was further explored by nationality. (South) Korean residents were identified as a subgroup of interest due to their status as the most populous non-Japanese nationality historically and their disproportionately high mortality rates. Age-standardized mortality rates and years of potential life lost (YPLL) were computed using vital statistics and life expectancy data from MHLW.

Results: Of the 20,775 COVID-19 deaths in 2020/21, 98.3% were Japanese nationals, while non-Japanese residents accounted for the remaining 358 deaths. The nationwide age-standardized mortality rate was 16.5 per 100,000 individuals, with 14.9 for non-Japanese residents. Among older adults (≥65 years), the mortality rate for non-Japanese residents was 152.3 per 100,000, compared to 52.5 for the general population. Koreans accounted for 193 (53.9%) of non-Japanese deaths. Crude mortality rate was 51.5 per 100,000 for this group, sharply increasing among older adults (162.1). Total YPLL due to COVID-19 in 2020/21 was 76,544.1 years, with YPLL rates of 59.5 years per 100,000 among Japanese nationals, 178.4 for non-Japanese residents, and 268.2 for Koreans.

Conclusions: Notable disparities in COVID-19 mortality were uncovered, particularly among older non-Japanese and Korean residents. With growing diversity domestically, these findings suggest a need for institutional monitoring of health outcomes by nationality to better inform equitable public health in Japan.

Introduction: Loneliness has been increasingly recognized as a determinant of adverse health outcomes, including mortality and cardiovascular disease, primarily based on evidence from Western countries. However, data from East Asian populations using standardized loneliness measures remain limited. This study aimed to examine the associations between loneliness, assessed using the University of California, Los Angeles (UCLA) 3-Item Loneliness Scale, and multiple health-related outcomes among adults in Japan.

Methods: We conducted a cross-sectional analysis using data from a nationwide, internet-based panel survey of the general population in Japan conducted in 2024. Participants aged 18-79 years were included. Loneliness was defined using the UCLA 3-Item Loneliness Scale. Primary outcomes were poor self-rated health and high symptom burden, assessed using the Somatic Symptom Scale-8. Weighted multivariable logistic regression models were used to estimate associations, adjusting for demographic, socioeconomic, and health-related factors, with additional adjustment for psychological distress.

Results: Among 25,014 participants (mean [standard deviation {SD}] age, 50.0 [17.4] years; 49.9% men), 12,582 (50.3%) were classified as lonely. Loneliness was significantly associated with poor self-rated health (adjusted odds ratio [AOR], 2.71; 95% confidence interval [CI], 2.40-3.07) and high symptom burden (AOR, 3.61; 95% CI, 3.21-4.05). Loneliness was also associated with a higher prevalence of self-reported chronic diseases after adjusting for demographic, socioeconomic, and health-related factors; these associations were attenuated after further adjustment for psychological distress. In addition, lonely participants were less likely to report having a family doctor and demonstrated different patterns of engagement with preventive healthcare services.

Conclusions: Loneliness was associated with poorer perceived health, greater symptom burden, and altered healthcare-seeking behaviors, with attenuation after adjustment for psychological distress. These findings suggest that loneliness reflects health-relevant vulnerability beyond traditional risk factors and underscore the importance of addressing loneliness within population health strategies, even in healthcare systems with high accessibility.

Introduction: Social isolation is an important social determinant of health, but its relationship with health-related outcomes remains incompletely understood. This study examined whether structural social isolation is associated with subjective health, symptom burden, chronic disease diagnoses, and healthcare-seeking behaviors in a nationwide Japanese population.

Methods: We conducted a nationwide cross-sectional study using data from the 2024 Japan coronavirus disease 2019 and Society Internet Survey, including adults aged 18-79 years. Social isolation was assessed using the Lubben Social Network Scale-6. Primary outcomes were poor self-rated health and high symptom burden, defined by the Somatic Symptom Scale-8. Secondary outcomes included self-reported chronic diseases and healthcare-seeking behaviors.

Results: Among 25,014 participants (mean age: 50.0 years; 49.9% men), 59.3% were classified as socially isolated. Social isolation was associated with higher odds of poor self-rated health (adjusted odds ratio [AOR]: 1.54, 95% confidence interval [CI]: 1.32-1.81) and high symptom burden (AOR: 1.23, 95% CI: 1.09-1.38). In contrast, social isolation was not associated with a higher prevalence of most chronic diseases. Socially isolated individuals were also less likely to have a regular doctor or receive preventive services.

Conclusions: Structural social isolation was associated with poorer subjective health and greater symptom burden but not with a higher prevalence of diagnosed chronic diseases. These findings suggest that reliance on diagnosis-based indicators alone may underestimate the health needs of socially isolated individuals, even in healthcare systems with broad accessibility.

Introduction: To prevent the spread of infectious diseases, general day care centers in Japan ask children to not attend when they are feeling unwell, even if they only have mild symptoms. Thus, when a child becomes ill, their continuity of childcare is disrupted. For this reason, specialized nurseries for children who are mildly ill have been established in Japan, aiming to ensure continuity of care. However, there is limited knowledge regarding the impact on nursery use caused by the distance between a child's residence and the nearest facility.

Methods: This survey targeted 105 major cities nationwide: 20 designated cities, 23 special wards of Tokyo, and 62 core cities. Using panel data analysis with generalized estimating equations, I determined the monthly number of users of day care for mildly ill children from April 2018 to March 2023 based on the average shortest distance in each city from each child's residence to the corresponding facility. The analysis was adjusted for factors that included general infectious disease trends, childcare capacity for mildly ill children, child population, the coronavirus disease 2019 (COVID-19) pandemic, and presence/absence of a declaration of state emergency/priority infection control measures.

Results: Both before and during the COVID-19 pandemic, the utilization rate decreased by a factor of 0.825 for every 1-km increase (approximately 17.5% decrease per kilometer) in the shortest distance to a nursery for mildly ill children. When the distance reached 12 km, the utilization rate decreased to 10%.

Conclusions: Defining the service area as the distance range where utilization rates become one-tenth to equivalent compared with childcare facilities in the same neighborhood as a child's home, the radius remained approximately 12 km both before and during the COVID-19 pandemic.

Introduction: Malignant fungating wounds often produce strong malodors caused by anaerobic bacterial proliferation, which severely impairs the quality of life of cancer survivors and their caregivers. Topical metronidazole is widely used as a first-line option for odor control; however, differences in the rheological (Q3) attributes between brand-name and generic gel formulations may influence spreadability, retention on the wound surface, and overall usability. The study aimed to compare the rheological properties of brand and generic metronidazole gels marketed in Japan and to discuss their potential impact on malodor management.

Methods: Brand (Rozex^Ⓡ Gel 0.75%) and generic metronidazole gels were evaluated using a rotational rheometer. Flow behavior, thixotropy, viscoelasticity (G′, G″), linear viscoelastic region (LVR), and frequency sweep responses were measured at 25℃. Excipients were compared qualitatively based on package inserts.

Results: Both formulations exhibited shear-thinning behavior; however, the brand gel showed consistently higher viscosity across all shear rates, with a pronounced difference at low shear rates relevant to wound application. The brand product demonstrated a narrower thixotropic hysteresis loop (approximately 26-fold difference), indicating faster structural recovery. Viscoelastic measurements showed higher G′ values and a wider LVR for the brand gel, suggesting a stronger gel network. Frequency sweep analysis revealed strong-gel behavior for the brand formulation, whereas the generic gel exhibited weak-gel characteristics. These rheological differences corresponded to differences in base polymers―carboxyvinyl polymer in the brand gel and hydrophobically modified hydroxypropyl methylcellulose in the generic.

Conclusions: Although containing identical active ingredients, the two formulations exhibit distinct rheological profiles that may affect clinical handling and usability in malodor management. Q3 attributes should be considered when selecting topical products for cancer survivors with fungating wounds.

Introduction: Postoperative skeletal muscle mass tends to decrease early, potentially affecting long-term prognosis and physical function. This study aimed to assess the extent of and factors associated with postoperative skeletal muscle loss (PSML) occurring during hospitalization in patients with non-small cell lung cancer (NSCLC) who were undergoing lobectomy.

Methods: This retrospective cohort study included patients who underwent lobectomy for NSCLC. The extent of PSML during hospitalization―defined as the skeletal muscle mass index (SMI) loss rate [(preoperative SMI − SMI before discharge) / preoperative SMI × 100]―was evaluated along with associated factors, including patient background, rehabilitation assessments, surgical parameters, and postoperative course variables.

Results: The cohort comprised 185 patients with a median age of 71.0 years (66.0-76.0), and 103 patients (55.7%) were male. The median SMI loss rate was 4.2%. Factors significantly associated with the SMI loss rate included female sex (B = 2.48; 95% confidence interval [CI]: 0.41-4.54; p = 0.018), body mass index (BMI) (B = 0.23; 95% CI: 0.07-0.38; p = 0.005), preoperative extracellular water-to-total body water ratio (ECW/TBW) (B = 223.80; 95% CI: 112.02-335.58; p < 0.001), difficulty completing three full meals per day by the fourth postoperative day (B = 1.69; 95% CI: 0.26-3.11; p = 0.020), and postoperative length of stay (B = 0.29; 95% CI: 0.06-0.52; p = 0.013).

Conclusions: Patients with NSCLC who underwent lobectomy experienced a median PSML of 4.2% during hospitalization. PSML was more likely to occur in female patients and in patients with higher BMI, higher preoperative ECW/TBW, difficulty completing full meals by the fourth postoperative day, and longer postoperative length of stay. Preventive strategies against PSML in patients with NSCLC should emphasize perioperative management and rehabilitation tailored to individual patient characteristics.

Background: The purpose of this study was to examine the reliability and validity of the Japanese version of the Family Satisfaction in the Intensive Care Unit (FS-ICU).

Methods: In the present study, confirmatory factor analysis (CFA) was conducted to examine whether the Japanese data retained the same factor structure as reported in development studies, and CFA was performed using the maximum likelihood estimation method.

Results: The CFA for the FS-ICU revealed acceptable model fit indices. The internal consistency of the FS‒ICU subscales was also evaluated. The Cronbach's alpha for the satisfaction with care subscale was 0.967, that for the information needs subscale was 0.935, and that for the process of making decisions subscale was 0.796, indicating high reliability for the first two subscales and acceptable reliability for the third. The FS-ICU score for satisfaction with care was significantly negatively correlated with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score and depression score, whereas information needs was significantly negatively correlated with HADS-A score (p < 0.05). However, no significant correlations between the FS-ICU and Impact of Event Scale-Revised scores were detected.

Conclusions: The Japanese version of the FS-ICU questionnaire was found to have acceptable reliability and validity in a Japanese population and can be used to drive improvements in ICU care.

Trial registration: Not applicable.

Background: During the coronavirus disease 2019 (COVID-19) pandemic, outpatient clinics were required to continue providing routine medical care amid uncertainty, limited resources, and concerns about staff safety. However, evidence describing operational infection control measures in clinic settings remains limited.

Methods: We conducted a cross-sectional questionnaire survey of medical facilities affiliated with the Minato Ward Medical Association in Tokyo and the Higashi Nagoya Medical Association in Aichi Prefecture, Japan. The survey was conducted between December 2023 and January 2024. The survey assessed facility characteristics, staffing patterns, infection control measures implemented during the COVID-19 pandemic, methods of information sharing among staff, and experiences of social impact such as discrimination. Descriptive statistics were used, and regional comparisons were performed where appropriate.

Results: Responses were obtained from 63 medical facilities, primarily outpatient clinics. Common infection control measures for staff included installing acrylic panels and protective sheets at reception areas, providing personal protective equipment, regularly monitoring temperatures, and canceling in-person staff gatherings. These measures were implemented in a substantial proportion of facilities across regions. Regarding information sharing, the use of digital communication tools was more frequent in clinics located in Tokyo than in those in Aichi Prefecture. A small proportion of facilities reported experiences of discrimination against staff, with no marked regional differences observed.

Conclusions: Outpatient clinics in Japan rapidly adopted practical infection control measures to protect staff during the COVID-19 pandemic. While many measures were universally implemented, certain operational practices, such as information-sharing methods, varied across regions. These findings provide practical insights into infection control preparedness for outpatient clinics facing future infectious disease emergencies.

Introduction: Inflammatory bowel disease (IBD) is a long-standing, recurrent disorder that affects not only physical health but also emotional well-being and social functioning, ultimately diminishing patients' health-related quality of life (HRQL). This paper assessed the association between psychological distress and perceived social support and HRQL in people with Crohn's disease (CD) and ulcerative colitis (UC).

Methods: A cross-sectional survey was conducted among 504 adults with IBD in outpatient gastroenterology clinics. Participants completed measures of psychological distress, perceived social support, and HRQL. Correlation, independent-samples t-tests, one-way analysis of variance, and multiple linear regression were used to analyze the data.

Results: There were significant negative correlations between psychological distress and social support (r = −0.53, p < 0.001) and between psychological distress and HRQL (r = −0.48, p < 0.001); however, there was a positive correlation between social support and HRQL (r = 0.62, p < 0.001). There was increased distress and poorer HRQL in females and younger adults. Patients with CD showed a higher level of distress and reduced HRQL compared to patients with UC. Regression revealed that HRQL was negatively predicted by psychological distress and disease activity, but positively predicted by social support and age.

Conclusions: HRQL is negatively associated with greater distress and active disease, whereas greater social support is positively associated with well-being of patients with IBD. Psychosocial care is potentially effective in improving clinical management.

Introduction: Japanese spotted fever (JSF) is an endemic tick-borne rickettsiosis in Japan that can cause severe illness and organ failure. Because early tetracycline therapy is crucial for improving outcomes, clarifying the clinical profile of JSF in endemic communities with an aging population and quantifying the impact of treatment delay are clinically important. We aimed to describe the clinical characteristics of patients with polymerase chain reaction (PCR)-confirmed JSF in an endemic region and to evaluate whether delays from symptom onset to minocycline initiation were associated with severe outcomes.

Methods: We conducted a retrospective cohort study in patients with PCR-confirmed JSF admitted to a tertiary hospital in eastern Hiroshima Prefecture between 2011 and 2023. Time intervals were calculated using calendar dates, with same-day events coded as 0 days. The primary outcome was severe JSF, defined as the need for invasive mechanical ventilation and/or renal replacement therapy. Logistic regression was used to assess associations between onset-to-minocycline delay and severe outcomes, adjusting for age and sex.

Results: Forty-two patients (median age, 73.5 years) were included. Severe outcomes occurred in 13 patients (31.0%), and 6 patients (14.3%) died during hospitalization. The median onset-to-minocycline interval was longer in severe cases than in non-severe cases (6.0 vs. 4.0 days; p = 0.035). In multivariable analysis, each 1-day delay in minocycline initiation was associated with higher odds of severe outcomes (adjusted odds ratio, 1.35; 95% confidence interval, 1.01-1.81; p = 0.043).

Conclusions: In this region with endemic JSF and with an older patient population, longer delays from symptom onset to minocycline initiation were associated with severe outcomes. Strategies to shorten onset-to-treatment intervals, including timely clinical examination and empiric tetracycline therapy when JSF is suspected, may improve outcomes in older communities with endemic JSF.

Introduction: Quantifying the impact of coronavirus disease (COVID) 2019 (COVID-19) on mortality has become increasingly challenging in the Omicron-variant era. This difficulty arises from reduced excess mortality, the presence of long COVID, and the lack of a strict definition of COVID-19-related death, which has led to inconsistencies in reported mortality rates. Accurate cause-of-death statistics are essential for health care policymaking.

Methods: We conducted a retrospective cohort study in patients aged ≥65 years who were admitted to the COVID-19 isolation ward of our hospital between July 1, 2021 and September 30, 2023. The primary outcome was survival to hospital discharge. Causes of death were classified according to the World Health Organization definition into four categories: COVID-19, COVID-19-associated complications, pre-COVID-19 medical conditions, and post-COVID-19 complications. The latter two categories were considered deaths unrelated to COVID-19.

Results: A total of 182 patients with mild or moderate COVID-19 were included for analysis. Among these, 23 (13%) died during hospitalization. Those who died were more likely to have moderate COVID-19, impaired physical or eating functions, and multiple comorbidities than were survivors. Of the 23 deaths, only 8 (35%) were attributed to COVID-19 or COVID-19-associated complications, whereas 15 (65%) were due to pre-COVID-19 medical conditions or post-COVID-19 complications. Concordance between Japanese public criteria for COVID-19-related death and our classification method was low (Cohen's κ = 0.223).

Conclusions: In this cohort of older patients with mild or moderate COVID-19, in-hospital mortality was relatively high. However, most deaths were not directly attributable to COVID-19. Larger studies are needed to further clarify mortality outcomes in this population.

Introduction: Breast cancer remains the most prevalent malignancy among women worldwide, with prognostic outcomes and therapeutic responses differing considerably across subtypes. The conventional staging framework developed by the Union for International Cancer Control (UICC), based on the Tumor, Node, Metastasis classification, reflects anatomical stage (AS) but overlooks biological characteristics. To address this limitation, the American Joint Committee on Cancer (AJCC) introduced the Prognostic Stage (PS) in its 8th edition, which integrates biomarkers including estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER2), and histological grade (HG). This study aimed to assess and compare the prognostic utility of UICC AS and AJCC PS in patients with high-risk luminal breast cancer.

Methods: This retrospective study included patients who underwent surgery for ER-positive, HER2-negative breast cancer at Tokyo Metropolitan Komagome Hospital from 2011 to 2018. High-risk classification was defined based on MonarchE trial criteria: axillary lymph node metastasis, tumor diameter ≥5 cm, HG3, or Ki-67 ≥20%. Staging was performed using both UICC AS and AJCC PS, and prognostic values were evaluated via Kaplan-Meier survival analysis.

Results: Among 105 eligible cases, 43 (41%) were downstaged when reclassified from UICC AS to AJCC PS. While UICC AS failed to yield significant stratification in terms of invasive disease-free survival (IDFS) and distant recurrence-free survival (DRFS), AJCC PS demonstrated significant prognostic discrimination (IDFS p = 0.014; DRFS p = 0.004).

Conclusions: American Joint Committee on Cancer PS offers superior prognostic stratification compared to UICC AS in high-risk luminal breast cancer. Its incorporation into clinical practice may enable more personalized treatment approaches, particularly when identifying candidates for adjuvant abemaciclib therapy. Further validation through larger, prospective studies is warranted.

Introduction: In this study, we aimed to evaluate the impact of sarcopenia and its severity on postoperative functional decline in patients undergoing cardiac surgery.

Methods: This retrospective cohort study included 161 patients (median age, 71 years; 75.8% male) who underwent elective cardiac surgery at a tertiary care hospital between April 2021 and November 2024. Functional decline was assessed by subtracting the preoperative Barthel Index (BI) score from the score at discharge. Sarcopenia severity was assessed based on the Asian Working Group for Sarcopenia 2019 criteria. Multiple linear regression models adjusted for relevant clinical and demographic factors were used to examine the associations among sarcopenia, severe sarcopenia, and functional decline.

Results: The mean (standard deviation) change in BI score was −1.4 (5.7). The overall prevalence of sarcopenia was 21.1%, comprising 7.5% (non-severe) sarcopenia and 13.7% severe sarcopenia cases. In the multivariate analysis, the presence of sarcopenia was significantly associated with postoperative functional decline (β = −0.185, p = 0.001), whereas severe sarcopenia exhibited a stronger association with postoperative functional decline (β = −0.268, p < 0.001).

Conclusions: These findings indicate that patients with severe sarcopenia require careful attention because of their higher risk of postoperative functional decline.

Introduction: Contrast-enhanced spectral mammography (CESM) provides diagnostic capability comparable to dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI); however, in Japan, CESM is not routinely performed because the use of iodinated contrast agents for CESM is not approved. Evidence on CESM from Japan is therefore scarce. This study assessed the feasibility, diagnostic performance, and patient experience of CESM in Japanese patients with breast cancer.

Methods: This study enrolled women aged 20-80 years with histologically confirmed breast cancer who were scheduled for surgery. CESM and DCE-MRI were performed within two months preoperatively. Images were independently interpreted by a breast radiologist. Tumor size, Breast Imaging Report and Data System (BI-RADS) category, and breast density were assessed and compared with postoperative pathology. Average glandular dose (AGD) and contrast-related reactions were evaluated. Patients answered questions regarding examination time, comfort, positioning, and preferred modality. Pearson correlation coefficients were calculated to assess the relationship among tumor sizes measured on CESM, DCE-MRI, and pathology.

Results: A total of nine patients (11 malignant lesions) were analyzed. CESM detected 10 lesions (detection rate 90.9%) and DCE-MRI detected all lesions (100%). Tumor size measured by CESM (r = 0.95) and DCE-MRI (r = 0.94) showed strong correlation with pathology. AGD averaged 3.1 mGy, and no allergic reactions occurred. Patients preferred CESM primarily due to shorter examination time, while noise and long duration were the main disadvantages of DCE-MRI.

Conclusions: CESM demonstrated high diagnostic performance that was comparable to DCE-MRI and superior to mammography, particularly for dense breasts. Considering its shorter examination time and favorable patient acceptance, CESM may serve as a valuable diagnostic option in Japan, thus warranting further clinical research.

Introduction: Ovarian metastases from colorectal cancer (CRC) are uncommon but are associated with poor prognosis and therapeutic challenges. These lesions may exhibit discordant responses to systemic therapy, suggesting site-specific biological heterogeneity. However, the molecular characteristics of CRC-associated ovarian metastases remain insufficiently defined. We aimed to characterize the circulating tumor deoxyribonucleic acid (ctDNA) landscape of ovarian metastatic CRC using a plasma-based deep sequencing approach.

Methods: Plasma samples from patients with CRC and ovarian metastases were analyzed using cancer personalized profiling by deep sequencing. Pathogenic mutations and copy-number alterations were identified to delineate the genomic features of this metastatic subset.

Results: Pathogenic genomic alterations were detected in the majority of patients. Canonical CRC driver mutations, including TP53, KRAS, and APC, were observed at frequencies comparable to those reported in large-scale genomic datasets such as The Cancer Genome Atlas. In addition, recurrent amplification of growth factor receptor genes, including EGFR, MET, and ERBB2, was identified. Detectable tumor-derived alterations in plasma indicate active ctDNA shedding from ovarian lesions, supporting the feasibility of noninvasive genomic profiling in this setting.

Conclusions: CRC-associated ovarian metastases retain the core genomic architecture of colorectal tumorigenesis while demonstrating recurrent receptor tyrosine kinase amplifications that may reflect adaptive clonal evolution within the ovarian microenvironment. Plasma-based ctDNA profiling provides a feasible approach for molecular characterization of this rare metastatic phenotype and may contribute to improved understanding of site-specific tumor biology.

Introduction: Pneumonia is the leading cause of death among older adults, and oral care contributes to pneumonia prevention. Disparities in access to dental care and socioeconomic factors may influence service use among community-dwelling older adults. Therefore, in this study, we examined the association between the regional utilization of domiciliary dental care (DDC) and pneumonia mortality, as well as the impact of area-level socioeconomic conditions.

Methods: In this nationwide ecological cross-sectional study, we used publicly available data from 335 secondary medical areas across Japan in 2023. The primary outcome was the standardized mortality ratio (SMR) for pneumonia. The primary explanatory variable was the DDC utilization ratio, and the secondary analysis used per-capita claims (PCC). Area-level socioeconomic status (area SES) was defined using the area deprivation index. Healthcare resources were included as covariates, and a Bayesian spatial analysis was performed using a conditional autoregressive model.

Results: Moran's I for the SMR for pneumonia was 0.361 (p < 0.01). In the conditional autoregressive model, the DDC ratio was significantly associated with the SMR for pneumonia (relative risk [RR]: 1.04; 95% confidence interval [CI]: 1.002-1.08). However, area SES showed no significant association (RR: 1.05; 95% CI: 0.998-1.10). The PCC was also significantly associated with the SMR for pneumonia (RR: 1.06; 95% CI: 1.01-1.11), whereas area SES showed no significant association (RR: 1.05; 95% CI: 0.998-1.10). The PCC were weakly and inversely correlated with area SES.

Conclusions: Both the DDC ratio and PCC were positively associated with the SMR for pneumonia, suggesting that DDC is concentrated among frail older adults at high risk. Socioeconomically deprived areas tended to have fewer claims per patient, implying that regional disparities hinder preventive and continuous dental care. Strengthening preventive interventions and improving access to support tailored to local health needs and socioeconomic contexts are required.

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) have traditionally been central to pharmacological pain management in Japan, but population aging and increased use of mechanism-based analgesics may be changing prescribing patterns. We compared oral analgesic prescribing between fiscal year (FY) 2014 and FY2022 using nationwide claims-based open data, focusing on age and sex differences.

Methods: We analyzed aggregated prescription volumes from the 1st and 9th editions of the National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data for FY2014 (April 2014-March 2015) and FY2022 (April 2022-March 2023). Analgesics were grouped as acetaminophen, NSAIDs, cyclooxygenase-2 selective inhibitors, weak opioids, duloxetine, neuropathic pain medications, and neurotropin. We calculated population-based prescription volume rates (per 1,000 population) using official population estimates and summarized patterns by sex and age group (<20, 20-64, ≥65 years). We also calculated within-age-group composition (percent share). Poisson regression with log(population) offset estimated incidence rate ratios (IRRs) comparing FY2022 versus FY2014 using robust standard errors; NSAID IRRs were further examined by age-sex strata.

Results: Total prescription volume increased from 3.69 × 10⁹ in FY2014 to 6.09 × 10⁹ in FY2022. Rates per 1,000 population increased in all age groups, with the largest absolute increase among adults aged ≥65 years. NSAIDs remained the most frequently prescribed class by rate in adults aged 20-64 years, but composition shifted away from NSAIDs toward acetaminophen and neuropathic pain medications, most notably in older adults. Overall IRR was 1.55, with large increases for acetaminophen (2.51), neuropathic pain medications (2.14), duloxetine (2.29), and weak opioids (1.88), while NSAIDs changed modestly (1.15). NSAID rates decreased in older female strata (IRR <1 from ages 70-74 years).

Conclusions: Oral analgesic prescribing in Japan increased substantially between FY2014 and FY2022, alongside age-specific shifts away from NSAIDs toward acetaminophen and neuropathic pain medications, particularly among older adults.

Introduction: Salter innominate osteotomy (SIO) is a well-established surgical procedure for the treatment of developmental dysplasia of the hip (DDH). Despite generally favorable outcomes, loss of correction before bone union remains a clinically relevant concern, particularly when fixation strength is insufficient. Angulated innominate osteotomy without bone grafting has been introduced to improve stability and reduce surgical invasiveness; however, fixation strategies for this technique have largely remained unchanged and continue to rely on Kirschner wires (K-wires), which may provide limited rigidity and be associated with implant-related complications.

Methods: We describe a modified angulated innominate osteotomy using 3.5-mm solid cortical screw fixation. The osteotomy was performed according to the angulated technique described by Morita et al., eliminating the need for bone grafting. Provisional fixation was achieved using 2.5-mm K-wires, which were subsequently exchanged for 3.5-mm cortical screws along the same trajectory without additional drilling. A retrospective review was conducted of seven consecutive female patients with DDH who underwent isolated SIO using this technique. Radiographic parameters were evaluated preoperatively, immediately postoperatively, and at 6 months postoperatively.

Results: The mean age at surgery was 5.0 years (range: 3.5-6.1 years), and the mean operative time was 90 minutes. Two cortical screws were used in four cases and three screws in three cases. No perioperative complications, correction loss, screw breakage, or implant-related failures were observed. Radiographic parameters demonstrated maintained correction at 6 months postoperatively in all hips. Full weight-bearing was achieved at a mean of 6.9 weeks, and implant removal was uncomplicated, with a mean operative time of 17 minutes.

Conclusions: This study demonstrates the feasibility and safety of cortical screw fixation in angulated innominate osteotomy. This technique provided stable fixation during the bone-healing phase without increasing surgical complexity and appears to be a reliable option for fixation.

Introduction: Docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy is the standard preoperative chemotherapy for advanced esophageal cancer. Although pegfilgrastim (PEG) is used for prophylaxis, the optimal timing remains unclear. This study aimed to evaluate the safety and efficacy of early PEG administration in DCF therapy.

Methods: We retrospectively analyzed 50 chemotherapy cycles in 28 patients who underwent preoperative DCF therapy. The patients were divided into two groups based on the timing of PEG administration: day 3 (Early group) and day 7 (Late group). We compared hematologic and nonhematologic toxicities between the groups.

Results: Early PEG administration significantly reduced leukopenia (Early group vs. Late group: 14% vs. 64%) and neutropenia (21% vs. 79%) and was associated with a lower incidence of febrile neutropenia (7% vs. 36%). Early PEG administration also reduced the incidence of grade ≥3 diarrhea and anorexia and improved food oral intake, weight loss, hyponatremia, and anorexia.

Conclusions: Early administration of PEG on day 3 during preoperative DCF therapy for esophageal cancer significantly reduced severe neutropenia and was associated with improved treatment tolerability compared to standard day 7 administration. These findings suggest that early PEG administration is a safe and effective strategy to enhance the tolerability of intensive chemotherapy.

Introduction: Japan is among the most rapidly aging countries worldwide, and the need for long-term respiratory care continues to grow. Long-term oxygen therapy (LTOT), home positive airway pressure (PAP), and home mechanical ventilation (HMV) are widely used for chronic respiratory diseases; however, nationwide long-term trends in their use remain insufficiently characterized. We aimed to examine recent national patterns in the use of these modalities.

Methods: We conducted a descriptive study using National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data from fiscal years (FYs) 2017 to 2023. The annual claim counts for LTOT, PAP, and HMV were extracted. Population-adjusted rates (claims per 100,000 population) were calculated using national demographic data. Subgroup analyses were performed by sex across five age groups (0-24, 25-44, 45-64, 65-74, and ≥75 years), reflecting the clinically meaningful stages of aging in Japan.

Results: The population-adjusted rate of LTOT use increased steadily across all years, age groups, and sexes. PAP use also increased consistently throughout the study period, with larger increases among older adults. In contrast, HMV use demonstrated only small overall changes, with a gradual increase that was most pronounced among adults aged 0-24 years, while a declining trend was observed among those aged ≥75 years. Similar patterns were observed in the age- and sex-stratified analyses.

Conclusions: The nationwide use of LTOT and PAP increased between FY 2017 and FY 2023, whereas HMV use exhibited age-dependent variation. These findings indicate shifting needs in home respiratory support, with growing demand for LTOT and PAP and age-divergent patterns of ventilator use. Continued monitoring is essential to anticipate future service requirements and inform planning for age-appropriate home respiratory care.

Background: Triplet therapy consisting of androgen deprivation therapy (ADT), docetaxel, and an androgen receptor signaling inhibitor (ARSI) has demonstrated survival benefits in patients with metastatic castration-sensitive prostate cancer (mCSPC), particularly those with high-risk disease. However, the feasibility of this intensive regimen is often limited by docetaxel-associated toxicity, especially in Japanese patients. Under the current Japanese health insurance system, darolutamide is the only ARSI approved for use in triplet therapy for mCSPC. Therefore, optimization of docetaxel administration is a key clinical issue.

Methods: The triplet therapy (androgen deprivation therapy + darolutamide + biweekly docetaxel) for high-risk metastatic castration-sensitive prostate cancer (TRIC) study is an investigator-initiated, single-center, open-label, single-arm phase II clinical trial designed to evaluate the efficacy and safety of triplet therapy consisting of ADT, darolutamide, and biweekly low-dose docetaxel (35 mg/m² every two weeks) in patients with high-risk mCSPC. High-risk disease is defined according to the castration-sensitive PC classification proposed by Kanazawa University (Canazawa) risk classification, which includes Gleason pattern 5, bone scan index ≥1.5, and lactate dehydrogenase ≥300 IU/L. The primary endpoint is prostate-specific antigen (PSA) response at three and six months. Secondary endpoints include overall survival, time to castration resistance, radiographic progression-free survival, safety, and other clinically relevant outcomes.

Results: This study will prospectively assess the feasibility, safety, and early efficacy of the proposed triplet regimen. PSA response rates, survival outcomes, and treatment-related adverse events will be analyzed to generate preliminary evidence regarding treatment activity and tolerability in this high-risk population.

Conclusions: The TRIC study will provide important prospective data on a modified triplet therapy tailored to the Japanese clinical setting. The findings are expected to inform future randomized trials and to contribute to the development of optimized treatment strategies for patients with high-risk mCSPC.

Trial registration: Japan Registry of Clinical Trials (jRCTs) 041240151, registered: December 18, 2025.

Japan's nursing policy has long been shaped by an implicit “closed-loop” assumption that language and licensure barriers will keep most nurses in a domestic labor market. Ten years after the Health Care 2035 vision was introduced, this assumption is weakening. Currency depreciation and widening international wage differentials, technology-enabled reductions in language-related preparation costs, and increasingly active global recruitment are together making outward mobility a realistic option for highly skilled nurses. Yet Japan lacks robust reintegration pathways for nurses who return with international education or experience, creating “brain waste” and accelerating loss of clinical leadership. This Opinion argues that nursing retention has become a national health system security issue directly affecting patient safety and system resilience rather than being a problem solvable within individual hospitals. Japan should pivot from ad hoc retention to an explicit “brain circulation” strategy, enabled by three policy levers: reimbursement mechanisms that make advanced nursing practice economically legible within the fee schedule, clinical-academic joint appointments that create landing zones for returnees, and scope-of-practice reform aligned with international standards.

Patients newly diagnosed with hematologic diseases frequently ask, “What should I eat to get better?” This question reflects both a deeply rooted societal narrative linking lifestyle to recovery and a desire for personal agency in moments of vulnerability. Nutrition remains an essential component of supportive care. However, for most malignant and clonal hematologic disorders, there is limited clinical evidence that specific diets or commercially marketed supplements alter disease biology or replace standard therapy. In the digital era, dietary narratives are amplified by social media, online advertising, and commercial interests, increasing the risk of misinformation and exploitation. We argue that clinicians and professional societies should strengthen public medical literacy, clearly distinguish supportive nutrition from disease-modifying therapy, and proactively protect patients from misleading health claims.

Most journals' and publishers' guidelines regarding the use of artificial intelligence (AI) in peer review contain a similar statement: “reviewers are prohibited from uploading the manuscript to software or AI-assisted tools or technologies where confidentiality is not assured.” I believe that reviewers should refrain from uploading not only the submitted manuscript but also their own review sheets to AI tools. This position is based on two reasons. First, even if AI tools state that uploaded data will be deleted upon request, actual deletion cannot be independently confirmed. Second, reviewers sometimes include highly confidential keywords or messages in the review sheet; uploading them may jeopardize confidentiality. My humble experiment indicates that even when deletion of uploaded data is requested, AI systems such as ChatGPT may retain materials for training purposes; thus, complete deletion is theoretically impossible. Authors are usually permitted to upload their own manuscripts for linguistic refinement. Although this may also jeopardize confidentiality, authors do so voluntarily and accept that risk. Reviewers, however, are entrusted with unpublished work and should therefore exercise far greater caution when considering the use of AI software. Editors and journals expect reviewers to evaluate the significance of the study and manuscript. The review sheet can, and perhaps should, be simple and straightforward, written in their own English. Because confidentiality cannot be independently verified and complete deletion cannot be guaranteed, reviewers should refrain from uploading manuscripts or review sheets to AI tools.

Although artificial intelligence (AI; such as ChatGPT) can improve manuscript readability, AI-related false descriptions (so-called hallucinations) and incorrect reference retrieval have been repeatedly reported. We tested (1) whether ChatGPT, when provided with medically correct inputs, generates a manuscript containing medically incorrect statements―particularly whether it misunderstands or overlooks “subtle but important” medical issues―and (2) whether ChatGPT cites inappropriate references. We input bullet points on placenta percreta, tasked ChatGPT-5 with generating a mini-review, and asked it to confirm whether the output was medically correct. We introduced a small, deliberate trap. In percreta, a recent conceptual change has gained increased attention: this condition is considered to result from uterine abnormality rather than abnormal placental invasion. This etiopathological shift could be misinterpreted as implying “weaker adherence” and therefore “less difficult surgery,” leading to the notion that percreta could be managed at secondary-level institutions. The ChatGPT-generated manuscript cited appropriate references and was almost medically correct, except for one critical issue: it stated that percreta could be managed in secondary-level institutions, which is incorrect and potentially dangerous. During the “confirmation” stage, ChatGPT raised a caution regarding this issue, but not in a definitive manner. An additional experiment was conducted on hypercholesterolemia. ChatGPT again failed to address an important issue, familial hypercholesterolemia, which requires a management strategy different from that for non-familial hypercholesterolemia. Overall, ChatGPT generated a linguistically appealing manuscript with largely correct context, but it produced incorrect and potentially dangerous statements in clinically critical areas. When incorrect statements are subtle rather than obvious, authors, journals, and readers may fail to recognize them. This is paradoxical: advances in AI may reduce “apparent” errors while generating less recognizable ones. When evaluating AI-assisted manuscripts, careful review by individuals with deep domain knowledge is mandatory.

This opinion paper focuses on disclosure of artificial intelligence (AI) use in medical writing; AI use beyond manuscript writing is outside its scope. Almost all journals require full disclosure of AI use. However, several barriers may hinder such disclosure. First, there is a lack of clear statements by journals on how disclosure is evaluated. Authors may be concerned that a linguistically polished manuscript accompanied by AI disclosure might be scored lower. Conversely, a journal might question the nonuse of AI assistance when a manuscript presents highly significant data written in uncomfortable English. Authors may fear that either AI “use” or “nonuse” could result in disadvantage. Second, criteria for disclosure remain unclear. Many journals require disclosure when AI is used to “create, review, revise, or edit” but not when it is used for “checking grammar, spelling, and similar tasks.” However, the distinction between “edit” and “grammar check” is a delicate one; prompts such as “edit” and “check grammar” may produce almost identical revisions. Third, it may become difficult to distinguish between one's original expressions and AI-aided revisions after several rounds of linguistic consultation. Authors may regard the final text as their own authorship rather than AI intervention. These three factors, intentionally or unintentionally, may prevent honest and full disclosure. Journals may consider stating two points. First, that the use or nonuse of AI tools does not affect acceptance or rejection, provided that such use adheres to journal guidelines and is accurately disclosed. Second, that disclosure information is accumulated as a resource for future analysis, contributing to a more transparent publication environment. Such clarification could reduce hesitation surrounding disclosure. Transparency, from both authors and journals, would become an asset to the medical community.