Epidemiology and Clinical Features of Epstein-Barr Virus and Cytomegalovirus Infections in Japanese Infants and Young Children

The recent clinical features of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections in young children in developed countries remain unclear. This study investigated the clinical features of EBV and CMV infections and the latest seroepidemiology in Japan. Seroprevalence was analyzed 303 stored serum samples using commercial Enzyme Immunosorbent Assay kits, and viral infections were investigated in a cohort of febrile children under 5 years of age. After maternal antibody levels declined, the seroprevalences of EBV and CMV gradually increased by adolescence to 42.9% and 57.1%, respectively. Among 2,732 febrile children, serum EBV and CMV DNAs were detected in 1.76% and 1.24%, respectively. Of 25 primary EBV-infected patients, 15 (60.0%) had infectious mononucleosis (IM) with significantly higher IM frequency, WBC, atypical lymphocyte ratios, AST, ALT, LDH, and EBV DNA load compared to EBV-reactivated patients. No CMV DNA-positive patients had IM. Among primary EBV-infected patients, those with IM were older and had more atypical lymphocytes and higher EBV DNA load than those without IM. The age of primary EBV infection appears to have decreased compared to reports from Western countries in the 1990s. Even among children under 5 years of age, 60.0% of those with primary EBV infection developed IM.

Diverticulitis in Older Adults: A Review of Etiology, Diagnosis, and Management

BACKGROUND

Diverticulitis accounts for over 300,000 hospitalizations annually in the United States and its incidence increases with age. Among older adults, diverticulitis is the fourth leading cause for emergency surgery. Older adults with multimorbidity and geriatric syndromes are often excluded from clinical studies, leaving a gap in the evidence needed to guide management. Here, we provide a clinically oriented review of the diagnosis and management of older adults with diverticulitis through the lens of age-friendly care.

METHODS AND RESULTS

We reviewed the literature describing the epidemiology, diagnosis, management, and prevention of diverticulitis in older adults. Due to age-related physiologic changes, the presence of geriatric syndromes, and multimorbidity, older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients. Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging. Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment.

CONCLUSIONS

Diverticulitis is a common disease that has a unique presentation among older individuals with limited evidence to guide management. Diagnosis and treatment should focus on what matters most to the patient, providing the most meaningful outcome possible within the context of multimorbidity, patient goals, symptom burden, and anticipated treatment outcomes.

Coordinated empathy in attending general practitioners: an interpretive phenomenological approach to constructing a conceptual model of empathy

BACKGROUND

Empathy in general practice is important because it contributes to patient satisfaction and clinical outcomes. However, few studies have examined the perceptions of empathy of attending physicians, who are skilled medical practitioners. From the perspective of interpretive phenomenology, we conducted the present study to conceptualize perceptions of empathy in attending general practitioners, and to identify experiences that influenced these perceptions.

METHODS

We conducted four semi-structured interviews with three board-certified attending general practitioners. The transcripts were analyzed using the Steps for Coding and Theorization procedure. The four components of empathy (moral, emotional, cognitive, and behavioral) were used as the theoretical framework for the analysis.

RESULTS

We found that the participants exhibited the moral component of empathy, such that they felt they were on a mission to understand and support their patients. Furthermore, they mainly used cognitive empathy to understand the feelings and thoughts of their patients. The participants also used behavioral empathy to convey a sense of understanding to their patients, with the intent of building trust and creating an atmosphere in which the patients felt relaxed and able to speak freely. In contrast, emotional empathy was less frequent because the participants observed emotional boundaries related to professionalism.

CONCLUSIONS

This study revealed new details about how attending general practitioners coordinate the four components of empathy and how they balance humanistic care with their objective standpoint as physicians. These findings are important in that they provide a model for physicians in terms of providing empathetic care while maintaining professional boundaries.

Nematode Infections in Commercially Important Squid Species: Distribution Patterns and Food Safety Issues

INTRODUCTION

Cephalopods represent a valuable fishery resource worldwide and play a crucial role in the marine food chain both as predators and prey but also as paratenic hosts for the transmission of Ascaridoids, including zoonotic nematodes of the Anisakidae family. This study aimed to assess the presence, tissue distribution and species composition of zoonotic parasites in four squid species marketed in Italy, coming from four different FAO areas.

METHODS

A total of 238 squid specimens, Illex sp., I. coindetii, I. illecebrosus and Todaropsis eblanae, were caught across four FAO areas and examined using both visual inspection and the UV-press method. The collected larvae were identified by morphological and molecular methods.

RESULTS

Third stage larvae of nematodes were detected in 22.3% of the squids (18.8% Illexsp., 18.3% I. coindetii, 48.8% I. illecebrosus and 23% Todaropsis eblanae), with Anisakis simplex (s.s), A. pegreffii, Hysterothylacium spp. and Lappetascaris spp. being identified through morphological and molecular analyses. The UV-press method has proved to be significantly more effective than visual inspection. Additionally, the lack of molecular data on Raphidascarididae species, particularly Lappetascarisspp., complicates taxonomic classification, emphasising the need for an integrative taxonomic approach combining morphological and genetic methods.

CONCLUSION

Given the increasing consumption of raw and undercooked cephalopods, these findings highlight the importance of monitoring zoonotic parasites and improving molecular techniques to enhance food safety regulations and minimise health risks to consumers.

Viral infections and immune modulation in bladder cancer: implications for immunotherapy

This review explores the intricate relationship between viral infections and Bacillus Calmette-Guerin (BCG) efficacy, emphasizing immune modulation mechanisms that may influence treatment outcomes. Since its introduction in 1976, intravesical BCG has been a cornerstone in managing non-muscle invasive bladder cancer (NMIBC) after transurethral resection of bladder tumors (TURBT). Despite its success, variability in response rates suggests that host immune status, influenced by persistent infections, immunosenescence, and antigenic overload, may play a crucial role in therapeutic effectiveness. Chronic viral infections can modulate T cell responses, leading to immune exhaustion and impaired antitumor immunity. This review discusses the interplay between viral antigenic load, immune dysfunction, and tumor microenvironment remodeling, highlighting their potential impact on immunotherapies. By integrating insights from virome analysis, immune profiling, and tumor characterization, this review proposes personalized strategies to enhance immunotherapy efficacy. A deeper understanding of viral-induced immune dysregulation may improve prognostic assessment, optimize treatment protocols, and reduce healthcare costs associated with bladder cancer. Future research should focus on targeted interventions to mitigate the immunosuppressive effects of chronic infections, ultimately improving patient outcomes in NMIBC management.

Performance of a virtual assistant based on ChatGPT-4 in the diagnosis of syndromes with orofacial manifestations

OBJECTIVE

To evaluate the performance of the virtual assistant "Syndromic Diseases and Orofacial Features" (SDOF), developed based on the Generative Pre-trained Transformer 4 model, in formulating diagnostic hypotheses and recommendations for syndromes with orofacial manifestations.

STUDY DESIGN

Twenty-six anonymized, previously diagnosed clinical cases, including clinical features and images, were selected. The assistant was trained using scientific references and configured to generate diagnostic hypotheses and suggest complementary exams. The responses were evaluated by two oral diagnosis specialists based on criteria such as accuracy, completeness, relevance, and comprehensibility. Statistical analysis was performed using RStudio software to calculate means and standard deviations.

RESULTS

The SDOF correctly identified 96.2% of the cases, with 80.8% being the first diagnostic hypothesis and 15.4% being the second. In only one case (3.8%), the correct diagnosis was presented as the third hypothesis. The assistant performed best in the criteria "Relevance," "Practicality," and "Readability," while "Completeness" and "Up-to-dateness" scored the lowest. Despite the high accuracy rate, the assistant failed to mention all diagnostic steps in 7.69% of the cases.

CONCLUSIONS

The SDOF demonstrated significant potential to assist in the diagnosis of orofacial syndromes, with promising accuracy rates. However, the tool still requires professional supervision and improvements in completeness and up-to-dateness.

Idiopathic mesenteric phlebosclerosis: a rare but important disease in Asian populations

Idiopathic mesenteric phlebosclerosis (IMP) is a rare form of ischemic colitis that predominantly impacts Asian populations. Despite some recognizable signs, there is a significant lack of awareness about IMP. In this review, we explore the etiology, pathogenesis, imaging manifestations, endoscopic traits, and therapeutic modalities of IMP. In addition, we discuss the deficiencies in the current comprehension of IMP and the potential research orientations in future.

Exploratory Investigation of Barriers to Writing Case Reports Among Japanese Physicians Who Participated in Web Study Sessions

OBJECTIVE

This study examined the barriers to writing case reports among Japanese physicians who participated in a web study series titled "Let's Write a Case Report! What you need to do to be Accepted" and explored differences in these barriers based on physicians' years of experience.

METHODS

The study design was cross-sectional in nature. Throughout August and November 2020, the respondents participated in the web study sessions. Using an 11-point scale, from -5 (not a barrier at all) to 0 (neither) to 5 (very much of a barrier), the 16 items interrogated which elements could be barriers to case report writing. Participants were divided into two groups: those with 10 or fewer years of postgraduation experience and those with 11 or more years of postgraduation experience. The basic attributes and possible barriers were compared between the groups using chi-squared and t-tests.

RESULTS

In total, 53 (62.4%) participants responded to the web-based questionnaire. In a comparison between the two groups, the following barriers were significantly higher in the 10 years or fewer group: having sufficient medical documentation to write a report, knowing how to write a case report, determining the main case points and clinical message, knowing how to search the literature, knowing how to obtain literature, meeting the financial cost of accessing literature. Although there were no significant differences, only the lack of motivation to write papers was perceived as a barrier by the 11 years or more group.

CONCLUSIONS

Determining the main case points and clinical message, selecting an appropriate journal for submission, and having adequate time to write a paper were the major barriers to writing a case report. Paper-writing motivation was crucial for those with longer clinical experience and experience in writing papers. These barriers were significantly more pronounced among those with fewer than 10 years of clinical experience than among those with 11 or more years of experience. Providing targeted support in developing case points and clinical messages will lead to an increase in the rate of case report writing.

A systematic review and meta-analysis of diagnostic performance comparison between generative AI and physicians

While generative artificial intelligence (AI) has shown potential in medical diagnostics, comprehensive evaluation of its diagnostic performance and comparison with physicians has not been extensively explored. We conducted a systematic review and meta-analysis of studies validating generative AI models for diagnostic tasks published between June 2018 and June 2024. Analysis of 83 studies revealed an overall diagnostic accuracy of 52.1%. No significant performance difference was found between AI models and physicians overall (p = 0.10) or non-expert physicians (p = 0.93). However, AI models performed significantly worse than expert physicians (p = 0.007). Several models demonstrated slightly higher performance compared to non-experts, although the differences were not significant. Generative AI demonstrates promising diagnostic capabilities with accuracy varying by model. Although it has not yet achieved expert-level reliability, these findings suggest potential for enhancing healthcare delivery and medical education when implemented with appropriate understanding of its limitations.

Inhibition of Renin Release, a Crucial Event in Homeostasis, is Mediated by Coordinated Calcium Oscillations within Juxtaglomerular Cell Clusters

BACKGROUND

Juxtaglomerular (JG) cells are sensors that control blood pressure (BP) and fluid-electrolyte homeostasis. They are arranged as clusters at the tip of each afferent arteriole. In response to a decrease in BP or extracellular fluid volume, JG cells secrete renin, initiating an enzymatic cascade that culminates in the production of angiotensin II (AngII), a potent vasoconstrictor that restores BP and fluid-electrolyte homeostasis. In turn, AngII exerts negative feedback on renin release concomitantly with increased intracellular Ca2+, preventing excessive circulating renin and hypertension. However, within their native structural organization, the intricacies of intracellular Ca2+ signaling dynamics and their sources remain uncharacterized.

METHODS

We generated mice expressing the JG cell-specific genetically encoded Ca2+ indicator (GCaMP6f) to investigate Ca2+ dynamics within JG cell clusters ex vivo and in vivo. For ex vivo Ca2+ imaging, acutely prepared kidney slices were perfused continuously with a buffer containing variable Ca2+ and AngII concentrations ± Ca2+ channel inhibitors. For in vivo Ca2+ image capture, native mouse kidneys were imaged in situ using multi-photon microscopy with and without AngII administration. ELISA measurements of renin concentrations determined acute renin secretion ex vivo and in vivo, respectively.

RESULTS

Ex vivo Ca2+ imaging revealed that JG cells exhibit robust and coordinated intracellular oscillatory signals with cell-cell propagation following AngII stimulation. AngII dose-dependently induced stereotypical burst patterns characterized by consecutive Ca2+ spikes, which inversely correlated with renin secretion. Pharmacological channel inhibition identified key sources of these oscillations: endoplasmic reticulum Ca2+ storage and release, extracellular Ca2+ uptake via ORAI channels, and intercellular communication through gap junctions. Blocking ORAI channels and gap junctions reduced AngII inhibitory effect on renin secretion. In vivo Ca2+ imaging demonstrated robust intracellular and intercellular Ca2+ oscillations within JG cell clusters under physiological conditions, exhibiting spike patterns consistent with those measured in ex vivo preparations. Administration of AngII enhanced the Ca2+ oscillatory signals and suppressed acute renin secretion in vivo.

CONCLUSION

AngII elicits coordinated intracellular and intercellular Ca2+ oscillations within JG cell clusters, ex vivo and in vivo. The effect is driven by endoplasmic reticulum-derived Ca2+ release, ORAI channels, and gap junctions, leading to suppressed renin secretion.

Pharyngitis

While pharyngitis is a common primary care complaint, evidence reveals that this diagnosis is an area where antibiotic therapy is frequently misused. Appropriate diagnosis and management of pharyngitis is crucial to ensure antimicrobial stewardship and improve patient safety and outcomes. Pharyngitis etiologies include both infectious and noninfectious sources such as bacteria, viruses, fungal organisms, trauma, irritants, laryngopharyngeal reflux, and medications. Clinicians need to obtain a thorough history and careful physical examination, along with appropriate diagnostic testing when indicated, to ensure treatment plans are targeted toward the most likely pharyngitis etiology.

Prediction Models of Infective Endocarditis Usable Ahead of Performing Blood Cultures: A Narrative Review

Infective endocarditis (IE) often presents as a fever of unknown origin due to its extremely diverse clinical presentations, requiring diverse advanced medical equipment and tests to make a correct diagnosis. Whether a physician can suspect IE in a clinical setting is dependent on the physician's knowledge and experience. If IE is not suspected, antibiotics are administered without obtaining blood cultures, complicating the clinical course and prognosis. To avoid delayed diagnosis or entering the maze of diagnostic difficulties of IE cases, a prediction model to deduce IE likelihood can be used at an early stage after a patient's arrival at the hospital before blood culture examinations would be invaluable. In this study, we aimed to review the literature on such prediction models for IE diagnosis in existence, discussing their strengths and limitations. A narrative review was conducted by two researchers using PubMed. Comprehensive searches included the index terms "infective endocarditis" or "infectious endocarditis", coupled with "prediction model" or "prediction rule" or "predictive model". Five articles reporting one of the three prediction models were identified. The first model, developed for intravenous drug users (IDUs) admitted to the emergency departments of two to three hospitals showed a good area under the curve (AUC) of 0.8; however, the small sample size and overfitting of the model were a limit. The second model for inpatients in all departments of four hospitals showed an AUC of 0.783 with a shrinkage coefficient of 0.963, indicating high generalizability. Moreover, it featured the highest ease of use because it consisted of only five factors readily available in any hospital. The third model, developed for inpatients admitted to an emergency department at a single center, consisted of 12 factors and achieved the highest AUC (0.881). All models demonstrated fair to good AUC. The second model excelled in generalizability and ease of use, while the third model was superior in performance. To further improve the accuracy of each IE prediction, further high-level evidence studies, such as randomized controlled trials in multiple facilities, are mandatory.

Possible usefulness of fluorodeoxyglucose positron emission tomography in diagnosing polyarteritis nodosa: A case report and literature review

Polyarteritis nodosa (PAN) is a systemic rheumatic disease that affects medium-sized arteries. PAN is typically not associated with anti-neutrophil cytoplasmic antibodies and has no serological surrogate markers. Therefore, its diagnosis requires pathological findings. However, the positive rate of biopsy in diagnosing PAN is not high, and the biopsy area is often limited. Several investigators have reported the usefulness of imaging findings in diagnosing PAN, independent of pathological findings. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET)/CT has recently been approved for the diagnosis of large-vessel vasculitis in Japan. Several studies have also demonstrated the usefulness of FDG-PET/CT in diagnosing medium-vessel vasculitis. However, no studies have evaluated the usefulness of FDG-PET/CT for diagnosing PAN compared to other modalities, and it is not clear whether FDG-PET/CT is superior to other modalities for diagnosing PAN. Herein, we report a case of PAN and compare the usefulness of FDG-PET/CT with other modalities in diagnosing PAN.

Exploring prospects, hurdles, and road ahead for generative artificial intelligence in orthopedic education and training

Generative Artificial Intelligence (AI), characterized by its ability to generate diverse forms of content including text, images, video and audio, has revolutionized many fields, including medical education. Generative AI leverages machine learning to create diverse content, enabling personalized learning, enhancing resource accessibility, and facilitating interactive case studies. This narrative review explores the integration of generative artificial intelligence (AI) into orthopedic education and training, highlighting its potential, current challenges, and future trajectory. A review of recent literature was conducted to evaluate the current applications, identify potential benefits, and outline limitations of integrating generative AI in orthopedic education. Key findings indicate that generative AI holds substantial promise in enhancing orthopedic training through its various applications such as providing real-time explanations, adaptive learning materials tailored to individual student's specific needs, and immersive virtual simulations. However, despite its potential, the integration of generative AI into orthopedic education faces significant issues such as accuracy, bias, inconsistent outputs, ethical and regulatory concerns and the critical need for human oversight. Although generative AI models such as ChatGPT and others have shown impressive capabilities, their current performance on orthopedic exams remains suboptimal, highlighting the need for further development to match the complexity of clinical reasoning and knowledge application. Future research should focus on addressing these challenges through ongoing research, optimizing generative AI models for medical content, exploring best practices for ethical AI usage, curriculum integration and evaluating the long-term impact of these technologies on learning outcomes. By expanding AI's knowledge base, refining its ability to interpret clinical images, and ensuring reliable, unbiased outputs, generative AI holds the potential to revolutionize orthopedic education. This work aims to provides a framework for incorporating generative AI into orthopedic curricula to create a more effective, engaging, and adaptive learning environment for future orthopedic practitioners.

Use of Internet/Application-Based E-consults by General Practitioners in Japan to Resolve Patients' Problems: A Descriptive Observational Study

Introduction Electronic consultations (e-consults) refer to digital health technologies that enhance clinical information sharing and improve patients' access to expert healthcare providers. This study aims to describe the current utilization of the Internet/application-based e-consult system and to assess how effectively it resolves clinical questions. Methods Participants were general practitioners (GPs) who had installed the e-consult platform on their personal computers or cell phones. Hospital specialists who responded to the e-consults were previously registered on our e-consult platform and also participated in the study. We have developed and implemented an Internet/application-based e-consult system that GPs can use on their personal computers in Japan. In this descriptive study, GPs used the e-consult platform via an Internet/application to consult hospital specialists. The study period was from May 1, 2020, to October 31, 2021. The outcome measure was the resolution rate, calculated by dividing the number of cases resolved solely through e-consults by the total number of e-consult cases. Another outcome measure was the number of cases in which a plan was determined using e-consults. Other outcome measures were GP satisfaction, assessed using a 5-point Likert scale for e-consults, the number of chats required for a hospital specialist to respond, and the time from the GP's initial question to the hospital specialist's first response. Results Of the 329 e-consult cases identified, 91 conducted by GPs were included in the final analysis. The number of cases resolved using only e-consults was 47, resulting in a resolution rate of 52% in the study. The minor specialists exhibited the highest resolution rate using e-consults alone. The number of cases where a plan was determined using e-consults was 83, accounting for 91% of the total 91 cases. The level of GP satisfaction with the e-consult process was high, with a median satisfaction score of 5 on a 5-point Likert scale. Most e-consults received their initial response within two hours. The number of chats required for hospital specialists to respond was very low, with a median of only one chat being necessary. Conclusion The Internet/application-based e-consult system enabled GPs to address a wide range of medical problems. Further studies with large samples are necessary, even though these results serve as an important benchmark for future research on e-consults in Japan.

Heterogeneous afferent arteriolopathy: a key concept for understanding blood pressure-dependent renal damage

Hypertension, aging, and other factors are associated with arteriosclerosis and arteriolosclerosis, primary morphological features of nephrosclerosis. Although such pathological changes are not invariably linked with renal decline but are prevalent across chronic kidney disease (CKD), understanding kidney damage progression is more pragmatic than precisely diagnosing nephrosclerosis itself. Hyalinosis and medial thickening of the afferent arteriole, along with intimal thickening of small arteries, can disrupt the autoregulatory system, jeopardizing glomerular perfusion pressure given systemic blood pressure (BP) fluctuations. Consequently, such vascular lesions cause glomerular damage by inducing glomerular hypertension and ischemia at the single nephron level. Thus, the interaction between systemic BP and afferent arteriolopathy markedly influences BP-dependent renal damage progression in nephrosclerosis. Both dilated and narrowed types of afferent arteriolopathy coexist throughout the kidney, with varying proportions among patients. Therefore, optimizing antihypertensive therapy to target either glomerular hypertension or ischemia is imperative. In recent years, clinical trials have indicated that combining renin-angiotensin system inhibitors (RASis) and sodium-glucose transporter 2 inhibitors (SGLT2is) is superior to using RASis alone in slowing renal function decline, despite comparable reductions in albuminuria. The superior efficacy of SGLT2is may arise from their beneficial effects on both glomerular hypertension and renal ischemia. A comprehensive understanding of the interaction between systemic BP and heterogeneous afferent arteriolopathy is pivotal for optimizing therapy and mitigating renal decline in patients with CKD of any etiology. Therefore, in this comprehensive review, we explore the role of afferent arteriolopathy in BP-dependent renal damage.

Correlates of symptom burden in renal dialysis patients: a systematic review and meta-analysis

BACKGROUND

Patients receiving renal dialysis often experience a wide range of symptoms. These symptoms contribute to a significant symptom burden that significantly affects patients' quality of life and serves as a significant predictor of healthcare resource utilization and patient prognosis. It is necessary to synthesize existing evidence to draw reliable conclusions to deepen the understanding of symptom burden.

OBJECTIVE

A systematic review and meta-analysis were conducted to identify the relevant factors of symptom burden in patients receiving renal dialysis.

METHODS

The systematic review and meta-analysis was conducted by searching nine databases for studies reporting the correlates between symptom burden and demographic variables, disease factors, and psychosocial factors from inception to 24 June 2024. After two researchers independently conducted literature search, data extraction, and quality evaluation, meta-analysis was conducted using R Language and Stata 15.1 Software. This study has been registered in the PROSPERO.

RESULTS

Sixty-two studies were included in this review. Results showed that the symptom burden of renal dialysis patients was positively correlated with age, gender, working status, medical cost, dialysis age, quality of sleep, nutritional status, comorbidities, depression, anxiety, disease uncertain, avoidance coping and resignation coping, and negatively correlated with marital status, income, serum sodium, quality of life, social support, subjective well-being, and self-management ability.

CONCLUSIONS

Our findings reveal that many factors, including demographic, disease-related, and psychosocial variables, affect symptom burden. The results can supply information for health promotion and relief symptom burden for patients receiving renal dialysis.Registered number: CRD42024507577.

Diabetic kidney disease: the kidney disease relevant to individuals with diabetes

In individuals with diabetes, chronic kidney disease (CKD) is a major comorbidity. However, it appears that there is worldwide confusion regarding which term should be used to describe CKD complicated with diabetes: diabetic nephropathy, diabetic kidney disease (DKD), CKD with diabetes, diabetes and CKD, etc. Similar confusion has also been reported in Japan. Therefore, to provide clarification, the Japanese Diabetes Society and the Japanese Society of Nephrology collaborated to update the corresponding Japanese term to describe DKD and clearly define the concept of DKD. In this review, we briefly described the history of kidney complications in individuals with diabetes and the Japanese definition of the DKD concept and provided our rationale for these changes.

An Exploratory Study of the Associations Between Epstein-Barr Virus Antibodies and Forgiveness Among Recipients of Relational Transgressions in the USA

Forgiveness is an important component of many of the world's religions that also has benefits for individuals' health and relationships. Research on the health benefits of forgiveness is couched predominately in the stress and coping framework, which views forgiveness as buffering the stress associated with unforgiving feelings. This exploratory study (N = 47) elaborated on the stress and coping framework by investigating it in conversation with an evolutionary approach. Specifically, this study examined one's own forgiveness index (i.e., the interaction of exploitation risk and relationship value) as moderating an association between forgiveness and Epstein-Barr virus (EBV) antibodies. The results indicated that forgiveness shared no significant association with EBV antibodies at low (16th percentile) levels of relationship value (b = - 11, p = .643), but shared an increasingly significant negative association at moderate (50th percentile: b = - 49, p = .038) and high (84th percentile: b = - 84, p = .009) levels, suggesting that forgiveness was more strongly linked to enhanced immune function when occurring in higher valued relationships. Implications for religion, theory, and methodological comparison are discussed.

A Questionnaire Study of Leadership in General Medicine: General Physicians in Japan are Facing Challenges in Education and Research

Purpose

General physicians are required to demonstrate diverse leadership skills depending on their environment. It is essential for them to understand the characteristics of the medical institutions to which they belong and put this understanding into practice. Leadership skills are acquired through experience and training, and their acquisition is a goal in various medical training programs. However, these leadership skills are difficult to acquire because the specific leadership skills required in clinical practice, education, and research are not well defined. For example, in clinical practice, general physicians need to lead initiatives to improve patient outcomes, resource utilization, and the quality of medical care. However, the specific leadership skills required for these tasks are not explicitly defined. Based on the survey results on the leadership types that general physicians value in clinical practice, research, and education, in addition to expert opinions and a literature survey, we aimed to establish the leadership type necessary in general medicine.

Patients and Methods

A cross-sectional anonymous questionnaire survey was conducted from February 2 to 29, 2024, using Google Forms sent through email, targeting members of the Japan Society of Hospital General Medicine. The survey comprised multiple-choice and descriptive questions.

Results

Notably, 286 physicians responded to the survey (response rate: 12.5%); 82.9% were males. Of these, 56.3% said they could explain what leadership constitutes, and 57.0% wanted to attend leadership training. When asked about the most-demanded leadership types in each scenario, democratic and transformational leadership were the most selected in clinical practice (52.4%) and in education and research (26.6% and 31.8%, respectively), respectively.

Conclusion

Transformational leadership was the most important leadership type in education and research, indicating that many general physicians face challenges in these areas. Therefore, developing strategies to improve leadership skills in education and research within general medicine is crucial.

Current management of Staphylococcus aureus bacteremia in a Japanese university hospital

Objectives

Consultation with infectious disease specialists is associated with reduced patient mortality in the care of patients with Staphylococcus aureus bacteremia (SAB) through appropriate management of complications including infective endocarditis. This study aimed to determine the rates of confirmation of a negative blood culture, implementation of echocardiography, and administration of appropriate antibiotics in patients with SAB at a university hospital in Japan that provides general internal medicine and not an infectious disease consultation service.

Methods

We conducted a retrospective cohort study at Dokkyo Medical University Hospital in Japan. Patients eligible for inclusion in the study were ≥20 years of age with ≥1 positive blood culture for S. aureus identified in a clinical microbiology laboratory. The primary outcome was the proportion of patients with confirmation of a negative blood culture, implementation of echocardiography, and administration of appropriate antimicrobial agents.

Results

A total of 109 patients with SAB were included in the analysis. Follow-up blood cultures were collected in 91 patients and negative results were documented in 88 patients. Follow-up blood culture collection was performed within 4 days of the initial blood culture collection in 49 patients. Echocardiography was performed appropriately in 40 patients. Appropriate antibiotic therapy was administered in 36 patients.

Conclusions

Quality-of-care indicators were more commonly implemented in patients with SAB who received general internal medicine consultation than in those who did not.

The management and clinical outcomes of pregnancies in women with urea cycle disorders: A review of the literature and results of an international survey

An increasing number of women with urea cycle disorders (UCDs) are reaching child-bearing age and becoming pregnant. Improved diagnostics and increased awareness of inherited metabolic diseases has also led to more previously undetected women being diagnosed with a UCD during or shortly after pregnancy. Pregnancy increases the risk of acute metabolic decompensation with hyperammonemia-which can occur in any trimester, and/or the postpartum period, and may lead to encephalopathy, psychosis, coma, and even death, if not diagnosed promptly and treated appropriately. There are also (theoretical) concerns that a maternal UCD, or its treatment, may cause potential risks for the unborn child. Currently evidence on management and outcome of pregnancies in UCDs is limited to case reports and there are no clear guidelines. In order to inform management and investigate outcomes of pregnancies in women with a UCD, we performed a retrospective review of published cases and analyzed data collected from an international online survey. We conclude that, although risk during the intra- and postpartum period exists, multidisciplinary management by an experienced team and a prospective plan usually result in successful pregnancy, labor, delivery, and postpartum period. No deaths were reported in mothers managed accordingly. With the exception of male neonates with Ornithine Transcarbamylase deficiency, the clinical outcome of children born to mothers with UCDs appears positive, although follow-up is limited. The outcome for women presenting with a first acute metabolic decompensation during pregnancy or postpartum is less favorable. Deaths were associated with diagnostic delay/late management of hyperammonemia in previously undiagnosed women.

An In Silico Modelling Approach to Predict Hemodynamic Outcomes in Diabetic and Hypertensive Kidney Disease

Early diagnosis of kidney disease remains an unmet clinical challenge, preventing timely and effective intervention. Diabetes and hypertension are two main causes of kidney disease, can often appear together, and can only be distinguished by invasive biopsy. In this study, we developed a modelling approach to simulate blood velocity, volumetric flow rate, and pressure wave propagation in arterial networks of ageing, diabetic, and hypertensive virtual populations. The model was validated by comparing our predictions for pressure, volumetric flow rate and waveform-derived indexes with in vivo data on ageing populations from the literature. The model simulated the effects of kidney disease, and was calibrated to align quantitatively with in vivo data on diabetic and hypertensive nephropathy from the literature. Our study identified some potential biomarkers extracted from renal blood flow rate and flow pulsatility. For typical patient age groups, resistive index values were 0.69 (SD 0.05) and 0.74 (SD 0.02) in the early and severe stages of diabetic nephropathy, respectively. Similar trends were observed in the same stages of hypertensive nephropathy, with a range from 0.65 (SD 0.07) to 0.73 (SD 0.05), respectively. Mean renal blood flow rate through a single diseased kidney ranged from 329 (SD 40, early) to 317 (SD 38, severe) ml/min in diabetic nephropathy and 443 (SD 54, early) to 388 (SD 47, severe) ml/min in hypertensive nephropathy, showing potential as a biomarker for early diagnosis of kidney disease. This modelling approach demonstrated its potential application in informing biomarker identification and facilitating the setup of clinical trials.

Hospital crisis management in the epidemic: A qualitative study

Background

Despite the advances in medical science, the epidemic of infectious diseases has faced serious challenges to the health system of countries, so the purpose of this study was to identify obstacles and management strategies to prepare for planning preventive measures and better care in dealing with infectious diseases in hospitals.

Method

The current qualitative research was of the grounded theory type, which was conducted in 2023. The semistructured interview questions were obtained from experts. The initial selection of the sample was made from experts in the field of health and treatment from all over the country. The snowball method was used to increase the sample volume until it reached sufficient Value. After analyzing the data through MAXQDA2020 software, this research reached saturation by interviewing 20 experts.

Results

Four main areas, 15 subthemes, and 93 codes were identified in the management of epidemics, which included leadership and management (planning, physical structure, information management, financial resources, manpower, medicine and equipment, and internal and external coordination), Stewardship (macro policy and syndromic care system), safety and resilience (crisis management and emergency and disaster risk management), management of infectious diseases (instructions, education, infection prevention and control, treatment management).

Conclusion

This study presents the strategies of the health system in dealing with the epidemic of infectious diseases to overcome the obstacles and challenges of preparation and response, which can help health managers in designing future programs, and finally, it shows that hospitals should have a plan for resilience in crises.

Diagnostic Challenges in Nephrotic Syndrome Presenting With Venous Thromboembolism

Nephrotic syndrome (NS) has a well-established relationship with hypercoagulability and, while rare, is known to present with unprovoked venous thromboembolism (VTE). Here, we present a case of seemingly unprovoked deep vein thrombosis and pulmonary embolism as presenting features of NS. We explore the challenge of timing diagnostic renal biopsy with necessary therapeutic anticoagulation, particularly in patients who present with unstable or extensive VTE. We also examine relevant factors in selecting an anticoagulant and discuss emerging treatment modalities in NS. This case underscores the complexity of medical decision-making in NS presenting with VTE and highlights the importance of multi-disciplinary consideration of patient-specific risks and benefits.

Gegen Qinlian Decoction Combined with Conventional Western Medicine for the Treatment of Infectious Diarrhea: A Systematic Review and Trial Sequential Analysis

INTRODUCTION

Infectious diarrhea (ID) is a highly prevalent disease worldwide that poses a substantial risk to human well-being. In China, numerous clinical studies have investigated the efficacy of Gegen Qinlian decoction (GGQLD) in treating ID. However, there is a need for additional rigorous and evidence-based medical research to enhance physicians' confidence in their prescribing practices.

METHODS

Seven Chinese and English databases were systematically searched. The Cochrane Risk of Bias tool was used to assess the quality of the included studies. Meta-analysis was conducted using RevMan 5.3, and Stata 16.0 was used for the sensitivity analysis. Trial sequential analysis was performed using TSA v0.9, and GRADEprofiler was utilized to evaluate the quality of evidence.

RESULTS

A total of 12 randomized controlled trials (RCTs) involving 1,240 patients were included. The meta-analysis demonstrated that the combination of GGQLD with conventional Western medicine had better effects on clinical efficacy (relative risk [RR] = 1.15, 95% confidence interval [CI] [1.10, 1.20]), duration of diarrhea symptoms (weighted mean difference [WMD] = -10.96, 95% CI [-11.97, -9.96]), duration of abdominal pain symptoms (WMD = -12.01, 95% CI [-14.12, -9.90]), duration of fever symptoms (WMD = -11.91, 95% CI [-13.39, -10.43]), interleukin-6 levels (WMD = -113.59, 95% CI [-113.03, -108.14]), and tumor necrosis factor-α levels (WMD = -62.18, 95% CI [-65.25, -59.11]) and that no significant adverse reactions occurred (RR = 0.45, 95% CI [0.10, 1.97]). The sample size of the included studies reached the expected size. The quality of evidence for outcome indicators was rated as low or very low.

CONCLUSIONS

The combination of GGQLD with conventional Western medicine demonstrates promising efficacy and safety in treating ID. Nonetheless, more high-quality RCTs are required to confirm this conclusion.

Hospitalists' COVID-19 management roles in hospitals without infectious disease specialists

BACKGROUND

Hospitalists may work in a variety of clinical settings to manage COVID-19 cases. However, the extent of their involvement in COVID-19 care is unknown, particularly in hospitals without infectious disease (ID) specialists.

METHODS

This study aimed to confirm whether hospitalists provided COVID-19 management in various clinical settings when ID specialists were unavailable. We conducted a multicenter cross-sectional study using a web-based questionnaire. The participants were full-time hospitalists working in Japanese academic community-based hospitals. The study period was from 15 January 2021 to 15 February 2021, during Japan's third wave of the COVID-19 pandemic. The primary outcome was the rate of hospitalists participating in COVID-19 inpatient management in hospitals with or without ID specialists.

RESULTS

ID specialists were absent in 31% of small hospitals (those with fewer than 249 registered beds), but only 4% of large hospitals (p < 0.001). Hospitalists were more likely to manage both COVID-19 inpatient care and emergency department care in hospitals without than with hospitals with ID specialists (76 versus 56% (p = 0.01) and 90 versus 73% (p = 0.01), respectively). After adjusting for confounders by multivariate analysis, hospitalists who worked in hospitals without ID specialists had higher odds of participating in COVID-19 inpatient care than those who worked in hospitals with such specialists (adjusted odds ratio: 3.0, 95% CI: 1.2-7.4).

CONCLUSION

Hospitalists were more likely to provide COVID-19 inpatient care in various clinical settings in hospitals without ID specialists.

Pelvic inflammatory disease associated with cytomegalovirus infection in an immunocompetent adult: Case report and literature review

Pelvic inflammatory disease associated with cytomegalovirus infection in immunocompetent adults might be difficult to diagnose because of the rarity and relatively inconspicuous symptoms of infectious mononucleosis. Even if the main complaint is lower abdominal pain, careful search for symptoms latent outside the abdomen could lead to the diagnosis.

As the Worm Turns-A Rare Cause of Intestinal Obstruction

BACKGROUND

Anisakiasis, a zoonotic disease caused by the nematode Anisakis, poses a significant concern for public health, particularly in regions with high consumption of raw or undercooked fish.

CASE PRESENTATION

We present a case report of a 41-year-old woman who developed severe abdominal symptoms, ultimately diagnosed with intestinal obstruction due to Anisakis infestation, requiring surgery. Despite the absence of prominent eosinophilia or specific radiological findings, the diagnosis was confirmed through histological examination, highlighting the importance of considering anisakiasis in patients with a history of raw seafood consumption.

CONCLUSION

The case underscores the diagnostic challenges associated with anisakiasis, emphasizing the need for increased awareness among healthcare professionals and the public regarding the risks of consuming raw or undercooked seafood. Effective management requires a multidisciplinary approach, including clinical assessment, imaging studies, and histological evaluation, to ensure timely diagnosis and appropriate treatment.

mRNA vaccine design for Epstein-Barr virus: an immunoinformatic approach

Epstein-Barr Virus (EBV), structurally similar to other herpes viruses, possess significant global health challenges as it causes infectious mononucleosis and is also associated with various cancers. Due to this widespread impact, an effective messenger RNA (mRNA) vaccine is paramount to help curb its spread, further underscoring the need for its development. This study, following an immunoinformatic approach, aimed to design a comprehensive mRNA vaccine against the EBV by selecting antigenic proteins, predicting Linear B-cell epitopes, cytotoxic T-cell lymphocyte (CTL) and helper T-cell lymphocyte (HTL) epitopes, and assessing vaccine characteristics. Seventy-nine EBV isolates from diverse geographical regions were examined. Additionally, the vaccine construct's physicochemical properties, transmembrane domains, solubility, and secondary structures were analysed. Molecular docking was conducted with Toll-Like Receptor 5 (TLR-5). Population coverage was assessed for selected major histocompatibility complex (MHC) alleles, and immune response was simulated. The result of this study highlighted a vaccine construct with high antigenicity, non-toxicity, and non-allergenicity and possessed favourable physicochemical properties. The vaccine's 3D structure is native-like and strongly binds with TLR-5, indicating a solid affinity with TLR-5. The selected MHC alleles provided broad universal population coverage of 89.1%, and the immune simulations suggested a robust and wide-ranging immunogenic response, activating critical immune cells, antibodies, and cytokines. These findings provide a solid foundation for further development and testing of the EBV candidate vaccine, offering potential solutions for combating EBV infections.

Right-sided acute diverticulitis in a North African country: Presentation and management in one surgical center

PURPOSE

Right-sided diverticulitis is a rare entity in North Africa. Therefore, it is usually misdiagnosed, and the management of cecal diverticulitis is aggressive in most cases, whereas nowadays, most studies recommend a conservative approach with promising results. This study aims to describe the presentation, management, and outcomes of right-sided diverticulitis (RSD) and to present the experience of one surgical center in Tunisia.

METHODS

This is a retrospective study including all patients presented with RSD, in the Department of Surgery "A" of the Charles Nicolle Hospital between 2007 and 2021.

RESULTS

Forty patients were included in our study. The mean age was 42 years with a standard deviation of 14. The sex ratio was 1.1. Only 2 patients had chronic constipation. All patients presented right-sided abdominal pain, and only 3 patients had diarrhea. Twenty one patients were diagnosed during surgery. Fourteen patients were treated successfully by conservative management. An operative procedure was performed in 26 cases: 21 had a diverticulectomy (80%), two had an ileal resection (8%), and three had a right colectomy (11.5%). No postoperative events occurred with a short hospital stay (5 ± 3 days). Follow-up showed no recurrences.

CONCLUSION

Right-sided diverticulitis has a lower incidence and complication rate compared to left-sided diverticulitis. Conservative treatment has demonstrated favorable outcomes in managing RSD, although the available evidence remains limited.

How to Overcome the Barriers Behind Writing Case Reports for Beginners and Young General Physicians

Background

Case reports are fundamental to clinical medicine that trace back to ancient Egypt preceding Hippocrates in the history of medicine. Case reports contribute to academic development and new clinical research. However, among cases presented at an annual academic conference for Japanese generalists, only a few cases were later published in peer-reviewed journals, highlighting potential barriers regarding the writing of case reports, such as mentorship absence. This paper aimed to offer guidance and strategies to novice and young general physicians in overcoming barriers and effectively composing case reports for international peer-reviewed journals.

Methods

This paper focuses on case reports for general physicians with extensive experience in writing case reports for international peer-reviewed journals. We conducted a narrative review to help beginners and young general physicians in writing case reports and discussed strategies for overcoming these barriers.

Results

We propose the following three tips as important processes for writing case reports: recognize the types of suitable cases for case reports; select a journal for submission using a list of candidate journals for general physicians; and organize the discussion section with one theme per paragraph. In addition, we provide a list of journals that specifically focus on case reports, along with important pointers for beginners and young general physicians that will assist authors in the field of general medicine in choosing appropriate journals for submission.

Conclusion

We hope that understanding and applying these tips will aid beginners and young general physicians in writing case reports.

Effect of Chronic Ethanol Consumption on Exogenous Glucose Metabolism in Rats Using [1-13C], [2-13C], and [3-13C]glucose Breath Tests

The C3 carbon of glucose molecules becomes the C1 carbon of pyruvate molecules during glycolysis, and the C1 and C2 carbons of glucose molecules are metabolized in the tricarboxylic acid (TCA) cycle. Utilizing this position-dependent metabolism of C atoms in glucose molecules, [1-13C], [2-13C], and [3-13C]glucose breath tests are used to evaluate glucose metabolism. However, the effects of chronic ethanol consumption remain incompletely understood. Therefore, we evaluated glucose metabolism in ethanol-fed rats using [1-13C], [2-13C], and [3-13C]glucose breath tests. Ethanol-fed (ERs) and control rats (CRs) (n = 8 each) were used in this study, and ERs were prepared by replacing drinking water with a 16% ethanol solution. We administered 100 mg/kg of [1-13C], [2-13C], or [3-13C]glucose to rats and collected expired air (at 10-min intervals for 180 min). We compared the 13CO2 levels (Δ13CO2, ‰) of breath measured by IR isotope ratio spectrometry and area under the curve (AUC) values of the 13CO2 levels-time curve between ERs and CRs. 13CO2 levels and AUCs after administration of [1-13C]glucose and [2-13C]glucose were lower in ERs than in CRs. Conversely, the AUC for the [3-13C]glucose breath test showed no significant differences between ERs and CRs, although 13CO2 levels during the 110-120 min interval were significantly high in ERs. These findings indicate that chronic ethanol consumption diminishes glucose oxidation without concomitantly reducing glycolysis. Our study demonstrates the utility of 13C-labeled glucose breath tests as noninvasive and repeatable methods for evaluating glucose metabolism in various subjects, including those with alcoholism or diabetes.

A Rare Case of Renal Vein Thrombosis Secondary to Oral Contraceptive Pills

Renal vein thrombosis (RVT) is a common complication of nephrotic syndrome and renal malignancy. However, its association with oral contraceptive use has rarely been reported. We report a case of a 29-year-old female with a history of oral contraceptive use, presenting with acute flank pain. On further investigation, she was found to have unilateral RVT. Oral contraception was discontinued, and she was started on therapeutic anticoagulation, initially with low-molecular-weight heparin, and then switched to apixaban. Her symptoms improved, and she is currently doing well. This case signifies the importance of proper history-taking and how oral contraception should be considered a significant risk factor for venous thromboembolism.

Writing Case Reports Can Improve Seven Components in Clinical Reasoning

Case reports provide scientific knowledge and opportunities for new clinical research. However, it is estimated that less than 5% of cases presented by Japanese generalists at academic conferences are published due to various barriers such as the complex process of writing articles, conducting literature searches, the significant time required, the reluctance to write in English, and the challenge of selecting appropriate journals for publication. Therefore, the purpose of this opinion paper is to provide clinicians with practical tips for writing case reports that promote diagnostic excellence. In recent years, clinical practitioners have been striving for diagnostic excellence and optimal methods to accurately and comprehensively understand the patient's condition. To write a case report, it is essential to be mindful of the elements of diagnostic excellence and consider the quality of the diagnostic reasoning process. We (the authors) are seven academic generalists who are members of the Japanese Society of Hospital General Medicine (JSHGM) - Junior Doctors Association, with a median of 7 years after graduation and extensive experience publishing case reports in international peer-reviewed journals. We conducted a narrative review and discussed ways to write case reports to promote diagnostic excellence, leveraging our unique perspectives as academic generalists. Our review did not identify any reports addressing the critical points in writing case reports that embody diagnostic excellence. Therefore, this report proposes a methodology that describes the process involved in writing diagnostic excellence-promoting case reports and provides an overview of the lessons learned. Based on our review and discussion, we explain the essential points for promoting diagnostic excellence through case reports categorized into seven components of clinical reasoning. These strategies are useful in daily clinical practice and instrumental in promoting diagnostic excellence through case reports.

Esophageal Ulceration Following the Ingestion of a Single Dose of Doxycycline: A Case Report

Doxycycline is one of the medications that cause drug-induced esophagitis. This condition occurs due to prolonged contact of the medications with the esophageal mucosa, leading to erosion, ulcers, and, in some cases, stricture of the esophagus. Chest pain, dysphagia, and odynophagia are the most common symptoms. Endoscopy is the gold standard for confirming the diagnosis. The treatment consists of stopping the offending medication and starting proton pump inhibitors (PPIs) and sucralfate. Herein, we describe a middle-aged man who presented with severe chest pain, odynophagia, and dysphagia that started two hours after ingesting the first doxycycline pill. An endoscopy showed multiple longitudinal ulcers in the distal esophagus. Symptoms significantly improved after starting a PPI and sucralfate, and feeding was resumed two days later. A follow-up with endoscopy after two months reported completely healed esophageal ulcers. In conclusion, doxycycline-induced esophageal injury is often an underdiagnosed and underreported condition. Physicians and patients should be more aware of doxycycline's detrimental effect on the esophagus, as it can induce esophageal ulceration even after a single dose if not administered properly. Therefore, all patients prescribed oral doxycycline should receive appropriate instructions to minimize this side effect.

Idiopathic mesenteric phlebosclerotic colitis associated with Chinese herbal medicine

Idiopathic mesenteric phlebosclerotic colitis(IMP) is a rare disease. At present, the etiology and pathogenesis are not clear, but the main patients are Asian people, and most of them have a history of taking Chinese herbal medicines. The disease has characteristic endoscopic and imaging manifestations. This paper shares a case of IMP, The patient came to our hospital for one year because of intermittent abdominal pain and diarrhea. It conforms to the typical manifestations of IMP. For patients who take Chinese herbal medicine for a long time, if they have clinical manifestations of gastrointestinal tract, it is necessary to consider the possibility of the disease to avoid serious consequences due to missed diagnosis.

Adult Vitamin B12 Deficiency-Associated Pseudo-Thrombotic Microangiopathy: A Systematic Review of Case Reports

Cobalamin-deficient thrombotic microangiopathy or vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy is a rare disorder that can be misdiagnosed as thrombotic thrombocytopenic purpura. Patients with this condition are at risk of receiving unnecessary plasmapheresis with a potential delay in appropriate therapy with vitamin B12 supplementation. There are no established diagnostic criteria for this condition in clinical practice. We performed a systematic review of case reports published between January 2018 and January 2023 to analyze the clinical characteristics, risk factors, and patterns of laboratory markers to improve the diagnostic criteria for this condition.

Direct Oral Anticoagulants in Nephrotic Syndrome: Our Experience and Literature Review

Nephrotic syndrome (NS) is one of the common presentations of kidney diseases both in children and adults. NS patients, particularly those with membranous nephropathy, have increased risk of thromboembolic events. Heparin and vitamin K antagonists (VKAs) continue to be commonly used as prophylactic and therapeutic agents, given the experience of use of these agents in NS and nonrenal indications of anticoagulation. The use of direct oral anticoagulants (DOACs) in NS is reported in some case series, conference abstracts, and a few small studies. We report our experience of using DOACs in 11 patients of NS with severe hypoalbuminemia. Out of 11, one patient required change of anticoagulation from DOACs to VKA and the rest of them did well with DOACs. There were no bleeding episodes in our study. We suggest larger studies to be carried out to better understand the use of these agents in NS.

Detection of PPB-Level H2S Concentrations in Exhaled Breath Using Au Nanosheet Sensors with Small Variability, High Selectivity, and Long-Term Stability

The continuous monitoring of hydrogen sulfide (H2S) in exhaled breath enables the detection of health issues such as halitosis and gastrointestinal problems. However, H2S sensors with high selectivity and parts per billion-level detection capability, which are essential for breath analysis, and facile fabrication processes for their integration with other devices are lacking. In this study, we demonstrated Au nanosheet H2S sensors with high selectivity, ppb-level detection capability, and high uniformity by optimizing their fabrication processes: (1) insertion of titanium nitride (TiN) as an adhesion layer to prevent Au agglomeration on the oxide substrate and (2) N2 annealing to improve nanosheet crystallinity. The fabricated Au nanosheets successfully detected H2S at concentrations as low as 5.6 ppb, and the estimated limit of detection was 0.5 ppb, which is superior to that of the human nose (8-13 ppb). In addition, the sensors detected H2S in the exhaled breath of simulated patients at concentrations as low as 175 ppb while showing high selectivity against interfering molecules, such as H2, alcohols, and humidity. Since Au nanosheets with uniform sensor characteristics enable easy device integration, the proposed sensor will be useful for facile health checkups based on breath analysis upon its integration into mobile devices.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.

An Overview of the Unfolded Protein Response (UPR) and Autophagy Pathways in Human Viral Oncogenesis

Autophagy and Unfolded Protein Response (UPR) can be regarded as the safe keepers of cells exposed to intense stress. Autophagy maintains cellular homeostasis, ensuring the removal of foreign particles and misfolded macromolecules from the cytoplasm and facilitating the return of the building blocks into the system. On the other hand, UPR serves as a shock response to prolonged stress, especially Endoplasmic Reticulum Stress (ERS), which also includes the accumulation of misfolded proteins in the ER. Since one of the many effects of viral infection on the host cell machinery is the hijacking of the host translational system, which leaves in its wake a plethora of misfolded proteins in the ER, it is perhaps not surprising that UPR and autophagy are common occurrences in infected cells, tissues, and patient samples. In this book chapter, we try to emphasize how UPR, and autophagy are significant in infections caused by six major oncolytic viruses-Epstein-Barr (EBV), Human Papilloma Virus (HPV), Human Immunodeficiency Virus (HIV), Human Herpesvirus-8 (HHV-8), Human T-cell Lymphotropic Virus (HTLV-1), and Hepatitis B Virus (HBV). Here, we document how whole-virus infection or overexpression of individual viral proteins in vitro and in vivo models can regulate the different branches of UPR and the various stages of macro autophagy. As is true with other viral infections, the relationship is complicated because the same virus (or the viral protein) exerts different effects on UPR and Autophagy. The nature of this response is determined by the cell types, or in some cases, the presence of diverse extracellular stimuli. The vice versa is equally valid, i.e., UPR and autophagy exhibit both anti-tumor and pro-tumor properties based on the cell type and other factors like concentrations of different metabolites. Thus, we have tried to coherently summarize the existing knowledge, the crux of which can hopefully be harnessed to design vaccines and therapies targeted at viral carcinogenesis.

A broad wastewater screening and clinical data surveillance for virus-related diseases in the metropolitan Detroit area in Michigan

BACKGROUND

Periodic bioinformatics-based screening of wastewater for assessing the diversity of potential human viral pathogens circulating in a given community may help to identify novel or potentially emerging infectious diseases. Any identified contigs related to novel or emerging viruses should be confirmed with targeted wastewater and clinical testing.

RESULTS

During the COVID-19 pandemic, untreated wastewater samples were collected for a 1-year period from the Great Lakes Water Authority Wastewater Treatment Facility in Detroit, MI, USA, and viral population diversity from both centralized interceptor sites and localized neighborhood sewersheds was investigated. Clinical cases of the diseases caused by human viruses were tabulated and compared with data from viral wastewater monitoring. In addition to Betacoronavirus, comparison using assembled contigs against a custom Swiss-Prot human virus database indicated the potential prevalence of other pathogenic virus genera, including: Orthopoxvirus, Rhadinovirus, Parapoxvirus, Varicellovirus, Hepatovirus, Simplexvirus, Bocaparvovirus, Molluscipoxvirus, Parechovirus, Roseolovirus, Lymphocryptovirus, Alphavirus, Spumavirus, Lentivirus, Deltaretrovirus, Enterovirus, Kobuvirus, Gammaretrovirus, Cardiovirus, Erythroparvovirus, Salivirus, Rubivirus, Orthohepevirus, Cytomegalovirus, Norovirus, and Mamastrovirus. Four nearly complete genomes were recovered from the Astrovirus, Enterovirus, Norovirus and Betapolyomavirus genera and viral species were identified.

CONCLUSIONS

The presented findings in wastewater samples are primarily at the genus level and can serve as a preliminary "screening" tool that may serve as indication to initiate further testing for the confirmation of the presence of species that may be associated with human disease. Integrating innovative environmental microbiology technologies like metagenomic sequencing with viral epidemiology offers a significant opportunity to improve the monitoring of, and predictive intelligence for, pathogenic viruses, using wastewater.

Acute Cytomegalovirus Infection Associated With Erythema Multiforme-Like Eruption: A Case Report

Human cytomegalovirus infection usually proceeds asymptomatically in immunocompetent patients. In symptomatic forms, mononucleosis syndrome is the most common manifestation. However, atypical cases of cytomegalovirus infections in immunocompetent subjects are reported in the literature. Here, we describe a case of cytomegalovirus-related mononucleosis syndrome that presented with an atypical erythema multiforme-like skin rash and high fever. Very few cases have been described in the literature previously. In our case, the diagnosis was supported by specific serology, and human cytomegalovirus DNA was detected in the blood sample. The clinical picture resolved without the administration of antiviral therapy.

Right-sided colonic diverticulitis. Short and long-term surgical outcomes and 2-year quality of life

AIM

We aimed to investigate the short and the long-term outcomes and 2-year Quality of Life (QoL) of patients with right-sided colonic diverticulitis (RCD) surgically managed.

METHOD

We conducted an ambidirectional cohort study of patients with RCD undergoing surgery between 2012/2022. A colonoscopy was performed at 1-year post surgery. The enrolled patients completed the EuroQoL (EQ-5D-3L) during a regular follow-up visit at 12 and 24 months after surgery.

RESULTS

Three hundred nineteen patients with RCD were selected: 223 (70%) patients were treated by non-operative management (NOM) while 33 underwent surgery. Acute diverticulitis occurred in 30 patients: 9 (27.2%) were classified by CT as uncomplicated and 21 (63.6%) as complicated diverticulitis. Additionally, chronic diverticulitis occurred in 3 cases (9.2%). Specifically, 27 patients were classified by CT as 1a (81.8%) and 6 patients as 3 (18.2%). Right hemicolectomy was performed in 30 patients (90.8%), and ileo-caecectomy in 3 (9.2%). Nine (27.27%) experienced postoperative complications: 7 (77.7%) were classified according to the Clavien-Dindo as grade I-II, and 2 (22.2%) as grade III. No disease recurrence or colorectal cancer (CRC) was detected on colonoscopy. Thirty (90.8%) patients completed the 24-month follow-up. A statistically significant difference between preoperative and 24-month QoL index values (median 0.72; IQR = 0.57-0.8 vs. median 0.9; IQR = 0.82-1; p = 0.0003) was observed.

CONCLUSIONS

The study results demonstrate satisfactory surgical outcomes and a better QoL after surgery. No disease recurrence or CRC was observed at colonoscopy 1 year after surgery.

Combination of clinical information and radiomics models for the differentiation of acute simple appendicitis and non simple appendicitis on CT images

To investigate the radiomics models for the differentiation of simple and non-simple acute appendicitis. This study retrospectively included 334 appendectomy cases (76 simple and 258 non-simple cases) for acute appendicitis. These cases were divided into training (n = 106) and test cohorts (n = 228). A radiomics model was developed using the radiomic features of the appendix area on CT images as the input variables. A CT model was developed using the clinical and CT features as the input variables. A combined model was developed by combining the radiomics model and clinical information. These models were tested, and their performance was evaluated by receiver operating characteristic curves and decision curve analysis (DCA). The variables independently associated with non-simple appendicitis in the combined model were body temperature, age, percentage of neutrophils and Rad-score. The AUC of the combined model was significantly higher than that of the CT model (P = 0.041). The AUC of the radiomics model was also higher than that of the CT model but did not reach a level of statistical significance (P = 0.053). DCA showed that all three models had a higher net benefit (NB) than the default strategies, and the combined model presented the highest NB. A nomogram of the combined model was developed as the graphical representation of the final model. It is feasible to use the combined information of clinical and CT radiomics models for the differentiation of simple and non-simple acute appendicitis.

DiaNet v2 deep learning based method for diabetes diagnosis using retinal images

Diabetes mellitus (DM) is a prevalent chronic metabolic disorder linked to increased morbidity and mortality. With a significant portion of cases remaining undiagnosed, particularly in the Middle East North Africa (MENA) region, more accurate and accessible diagnostic methods are essential. Current diagnostic tests like fasting plasma glucose (FPG), oral glucose tolerance tests (OGTT), random plasma glucose (RPG), and hemoglobin A1c (HbA1c) have limitations, leading to misclassifications and discomfort for patients. The aim of this study is to enhance diabetes diagnosis accuracy by developing an improved predictive model using retinal images from the Qatari population, addressing the limitations of current diagnostic methods. This study explores an alternative approach involving retinal images, building upon the DiaNet model, the first deep learning model for diabetes detection based solely on retinal images. The newly proposed DiaNet v2 model is developed using a large dataset from Qatar Biobank (QBB) and Hamad Medical Corporation (HMC) covering wide range of pathologies in the the retinal images. Utilizing the most extensive collection of retinal images from the 5545 participants (2540 diabetic patients and 3005 control), DiaNet v2 is developed for diabetes diagnosis. DiaNet v2 achieves an impressive accuracy of over 92%, 93% sensitivity, and 91% specificity in distinguishing diabetic patients from the control group. Given the high prevalence of diabetes and the limitations of existing diagnostic methods in clinical setup, this study proposes an innovative solution. By leveraging a comprehensive retinal image dataset and applying advanced deep learning techniques, DiaNet v2 demonstrates a remarkable accuracy in diabetes diagnosis. This approach has the potential to revolutionize diabetes detection, providing a more accessible, non-invasive and accurate method for early intervention and treatment planning, particularly in regions with high diabetes rates like MENA.

Two pregnancies of an ornithine carbamoyltransferase deficiency disease carrier and review of the literature

BACKGROUND

the underlying cause of the deficiency of ornithine carbamoyltransferase (OTCD) is a gene mutation on the X chromosome. In females, the phenotype is highly variable, ranging from asymptomatic to neurologic compromise secondary to hyperammonemia and it can be prompted by numerous triggers, including pregnancy.

OBJECTIVE

the objective of this article is to report a case of two pregnancies of an OTCD-carrier, and to review the literature describing OTCD and pregnancy, parturition and postpartum.

METHODS

an extensive search in PubMed in December 2021 was conducted using different search terms. After screening all abstracts, 23 papers that corresponded to our inclusion criteria were identified.

RESULTS

the article focuses on the management of OTCD during pregnancy, parturition, and the postpartum period in terms of clinical presentation, ammonia levels and treatment.

CONCLUSIONS

females with OTCD can certainly plan a pregnancy, but they need a careful management during delivery and particularly during the immediate postpartum period. If possible, a multidisciplinary team of physicians, dietitians, obstetrician-gynecologist, neonatologists, pharmacists, etc. with expertise in this field should participate in the care of women with OTCD and their children during this period and in their adult life.