ABSTRACT Background Talaromyces marneffei (TM) is an opportunistic infectious fungus, and more patients in HIV‐negative populations are infected with TM. Methods We reviewed the adult patients with TM infections (TMIs) between November 1, 2020 and April 30, 2025. This single‐center retrospective study was conducted at a tertiary care hospital located in an urban area, eastern China. Patients with TMI were divided into the following four groups: the HIV group, the non‐HIV with solid organ transplant (SOT) group, the non‐HIV with stem cell transplantation (SCT) group, and the non‐HIV with other factors group. Results There were a total of 218 cases of talaromycosis: 165 in the HIV group, 16 in the non‐HIV with SOT group, 4 in the non‐HIV with SCT group, and 33 in the non‐HIV with other factors group. The number (proportion) of patients diagnosed through metagenomic next‐generation sequencing (mNGS) in the four groups was as follows: 51 (30.9%), 11 (68.8%), 2 (50.0%), and 25 (75.8%), respectively. The number (proportion) of patients who tested positive in both culture and mNGS was as follows: 19 (11.5%), 1 (6.3%), 0 (0.0%), and 1 (3.0%), respectively. Kaplan–Meier estimates indicated that the patients in the non‐HIV with SCT group had the worst prognosis and those in the non‐HIV with other factors group had poorer prognosis than the patients in the HIV group. Conclusions TMI in patients who are HIV‐negative without SOT may have poorer prognosis. If talaromycosis is suspected, mNGS can be an important supplementary tool for confirming TMI.
ABSTRACT Vitamin B12 deficiency is a potentially treatable cause of neurological and neuropsychiatric manifestations, including cognitive impairment, and may occur in the absence of anemia1. We report an older patient with severe vitamin B12 deficiency and progressive cognitive and functional decline who showed substantial improvement after vitamin B12 replacement. Although a direct causal relationship could not be established, this case highlights the importance of measuring serum vitamin B12 in patients with cognitive decline, even when the hemoglobin level is normal. Although the underlying cause of vitamin B12 deficiency could not be definitively established, autoimmune gastritis remained a possible etiology because intrinsic factor antibodies were positive.
Background:Primary care is an important setting for prevention, but implementation gaps may arise before clinicians can identify patients eligible for preventive services. We described self-reported preventive care implementation among Japanese primary care physicians and examined whether lower implementation co-occurred with eligibility-identification difficulty. Methods:We conducted a nationwide web-based cross-sectional survey of physician members of the Japan Primary Care Association from May to June 2025. Respondents reported recommendation consistency for 30 preventive services, difficulty identifying eligible patients, and perceived barriers. Service-level implementation and eligibility-identification difficulty were summarized in a two-axis map. Results:Among 258 respondents, 56.2% reported structured preventive care training and 53.9% used outpatient reminders. "Mostly achieved" recommendation was relatively high for hypertension, diabetes, and dyslipidaemia screening and influenza vaccination, but low for screening for domestic violence, chlamydia/gonorrhea, abdominal aortic aneurysm, anxiety, and depression, respiratory syncytial virus vaccination, and folic acid counseling. Difficulty identifying eligible patients was highest for domestic violence screening (14.0%), chlamydia/gonorrhea screening (13.6%), hepatitis C screening (10.5%), and respiratory syncytial virus vaccination (7.8%). Common barriers were time constraints, insufficient knowledge or skills, low patient interest, and financial or reimbursement issues. Conclusions:Self-reported implementation varied substantially across services. Some low-implementation services also involved eligibility-identification difficulty, suggesting an upstream implementation problem. Japanese primary care may need systems that make eligibility visible through training, reminders, prompts, registries, and team-based workflows.
Background:The prognostic significance of pharyngeal residue during routine swallowing assessment remains unclear in older adults at regional hospitals. Methods:We conducted a single-center retrospective cohort study of 107 consecutive patients (median age 87 years) undergoing swallowing assessment at a regional hospital in Japan (January 2021-December 2024; follow-up until June 2025). The primary outcome was all-cause mortality, and the secondary outcome was aspiration events. Time-to-event analyses used Kaplan-Meier methods, multivariable Cox proportional hazards models, and Fine-Gray subdistribution hazard models to account for the competing risk of death. Results:During a median follow-up of 72 days (IQR 36-156), 72 deaths and 63 aspiration events occurred. Pharyngeal residue was independently associated with aspiration events (HR 3.26; 95% CI 1.70-6.26; p < 0.001) and all-cause mortality (HR 2.65; 95% CI 1.38-5.10; p = 0.003). These findings were consistent in sensitivity analyses excluding antipsychotic use and in Fine-Gray competing risks analysis (SHR 2.76; 95% CI 1.51-5.04; p = 0.001). Dementia was also independently associated with mortality (HR 1.83; 95% CI 1.02-3.29; p = 0.044). Conclusions:Pharyngeal residue was independently associated with all-cause mortality and aspiration events, supporting its utility as a simple prognostic marker for risk stratification in older adults with suspected dysphagia.
ABSTRACT Background Despite the recognized benefits of specialty outpatient training for medical students, such settings present educational challenges. To address these, our university incorporated generalist support into specialty outpatient education. The present study aimed to explore what medical students learned from this program. Methods Fifth‐ and sixth‐year medical students who selected orthopedics or cardiology for their clinical clerkships were enrolled. During training at specialty outpatient clinics, the students conducted preliminary interviews with new patients under generalist supervision and received immediate feedback from the generalists. They then presented the cases to specialists and observed the subsequent examinations, receiving additional feedback. Afterward, they completed a reflection sheet. Text data from the reflections were analyzed thematically using open coding. Results Sixty‐four medical students participated. Four categories were generated based on learning from generalists: Efficient information gathering through the synergistic use of open and closed questions; understanding the psychosocial background of the patient and their family through the interpretive model; communication skills to build rapport with the patient; and awareness of the difficulty and importance of balancing patient interviews and chart documentation. From orthopedic specialists, two categories emerged: Proactive approaches emphasizing interviewing and physical examination rather than relying solely on referrals, and insights gained from actual clinical examinations and consideration for patients. From cardiology specialists, two categories were generated: Proactive interviewing and professional perspectives independent of referrals; and explanations that foster patient understanding and co‐creation of treatment plans. Conclusion Medical students gained distinct learning experiences from generalists and specialists through generalist‐supported outpatient training.
Background:Non-erosive reflux disease (NERD) is the most prevalent gastroesophageal reflux disease phenotype. However, lifestyle factors associated with reflux symptoms in the absence of erosive esophagitis, a presentation often classified as NERD in epidemiological studies, remain underexplored in Japan. This study aimed to investigate lifestyle factors associated with reflux symptoms without erosive esophagitis, stratified by obesity status. Methods:We conducted a cross-sectional study of 2116 Japanese adults undergoing annual health checkups, including upper endoscopy and lifestyle questionnaires. Multivariable logistic regression was used to identify factors associated with reflux symptoms without erosive esophagitis, stratified by BMI-defined obesity and abdominal obesity. Results:Reflux symptoms without erosive esophagitis were present in 18.6% of participants. In multivariable analysis, past smoking, current smoking, weight gain ≥ 10 kg since age 20 years, poor sleep, and hiatal hernia were independently associated with reflux symptoms without erosive esophagitis, whereas neither BMI-defined obesity nor abdominal obesity showed independent associations. In obesity-stratified analyses, smoking, weight gain, fast eating, poor sleep, and hiatal hernia were independently associated with reflux symptoms without erosive esophagitis among nonobese participants. However, formal interaction testing showed no significant effect modification by obesity status. Conclusions:Smoking, long-term weight gain, fast eating, poor sleep, and hiatal hernia are key factors associated with reflux symptoms without erosive esophagitis. These findings may help identify potentially modifiable factors associated with reflux symptoms without erosive esophagitis in primary care settings.
Background:Postnatal care encompasses multiple health and social domains requiring a comprehensive approach. Primary care physicians (PCPs) are well-positioned to provide postnatal care, but research on their practice remains limited. This study aimed to investigate PCPs' practice frequency and attitudes toward postnatal care, and to examine PCP attributes associated with postnatal care provision. Methods:We conducted a cross-sectional study with an online questionnaire targeting certified PCPs via the Japan Primary Care Association. The questionnaire assessed frequency, perceived importance, and educational experience across 13 postnatal care domains. Practice frequency and perceived importance were examined descriptively on a five-point Likert scale, and the association between PCP attributes and postnatal care provision was analyzed by logistic regression. Results:We analyzed 259 responses (response rate: 17.4%). Practice frequency was highest for follow-up of non-pregnancy-related chronic conditions (79%) and maternal health care maintenance (71%), and lowest for intimate partner violence (25%) and postpartum gynecological examination (20%). Mean perceived importance scores exceeded mean practice frequency scores across all postnatal care domains. Intimate partner violence showed the largest practice-attitude discrepancy. Having received education in one domain was positively associated with practice in that domain. Other factors related to practice included female gender, immunization of infants, physicians' experience with raising children or postnatal health problems, and practicing in a rural area. Conclusion:There were variations in practice frequency and discrepancies between practice frequency and attitudes across postnatal care domains among Japanese PCPs. Addressing medical education as a modifiable factor may help reduce these gaps.
ABSTRACT Background Treatment intensity in older adults with lymphoma is often reduced because of frailty, comorbidities, and poor performance status (PS). Whether chronological age or delivered treatment intensity better predicts outcomes remains unclear. Methods We retrospectively reviewed 79 patients aged ≥ 65 years with newly diagnosed lymphoma initiating first‐line therapy. Progression‐free survival (PFS) was the primary outcome and overall survival (OS) secondary. Relative dose intensity (RDI) effects were expressed as hazard ratios (HRs) per 10%‐point increase. Cox models adjusted for age, sex, Ann Arbor stage, Charlson Comorbidity Index (CCI), and PS; diffuse large B‐cell lymphoma (DLBCL) models additionally included the International Prognostic Index (IPI). Results Median RDI was lower in patients aged ≥ 75 years than in those aged 65–74 years (63.3% vs. 85.4%; p < 0.001). In the full cohort, higher RDI was independently associated with longer PFS (HR, 0.709; 95% CI, 0.576–0.873; p = 0.001), but not OS (HR, 0.814; 95% CI, 0.635–1.044; p = 0.106); higher CCI was associated with shorter OS (HR, 1.442; 95% CI, 1.046–1.988; p = 0.025). In the DLBCL subgroup, higher RDI was associated with longer PFS (HR, 0.217; 95% CI, 0.088–0.536; p < 0.001) and OS (HR, 0.320; 95% CI, 0.127–0.806; p = 0.016). Conclusions Higher RDI was associated with longer PFS in the full cohort and DLBCL subgroup, and with longer OS in DLBCL. RDI may provide prognostic information beyond age and IPI‐defined risk but may reflect physiological reserve and treatment tolerance. Prospective validation is required.
Background:A 34-year-old man presented to our primary care clinic with persistent pain and swelling of the right first metatarsophalangeal joint lasting 3 months. A previous clinic had suspected gout based on hyperuricemia, but urate-lowering therapy was repeatedly withheld because of ongoing inflammation, resulting in prolonged symptoms managed only with nonsteroidal anti-inflammatory drugs. Case Presentation:Ultrasound-guided joint aspiration yielded a dry tap owing to highly viscous chalky material. Point-of-care ultrasound demonstrated diffuse hyperechoic intra-articular deposits and a double contour sign without synovial hypervascularity on color Doppler. Conclusion:This case highlights the diagnostic utility of point-of-care ultrasound in prolonged monoarthritis when invasive aspiration is unsuccessful/contraindicated.
An 18-year-old man presented with fatigue and polyarthralgia refractory to nonsteroidal anti-inflammatory drugs (NSAIDs). He had no history of sore throat or other upper respiratory symptoms. Reactive arthritis was initially suspected. However, persistent symptoms, fever, polyarthritis, a cardiac murmur, atrioventricular block, and an elevated antistreptolysin O titer (739 IU/mL) suggested acute rheumatic fever. He met the revised Jones criteria for acute rheumatic fever. Treatment with amoxicillin and corticosteroids rapidly resolved his symptoms and electrocardiographic abnormalities.
Background:Annual urine testing using the urine albumin-to-creatinine ratio (UACR) or urine protein-to-creatinine ratio (UPCR) is recommended for diabetic kidney disease (DKD) screening, yet attainment in nonspecialist primary care in Japan remains approximately 20%, and evidence on whether audit-and-feedback can produce sustained improvement in this quality indicator (QI) is limited. We evaluated the impact of an audit-and-feedback intervention on urine testing QI attainment and its sustainability after active feedback ceased. Method:We conducted a single-center before-and-after study at an urban primary care clinic in Tokyo. QI attainment was measured across ten rolling 12-month windows. Three individualized feedback sessions delivered in 2024 each included physician-level attainment rates and appointment-based patient identification lists. Run chart analysis assessed process change, and a post-intervention physician survey examined facilitators and barriers using the COM-B framework. Results:The pre-intervention median attainment was 18.6%. Following the intervention, attainment rose from 19.7% to 53.7%, an increase of 34.0 percentage points, and the shift rule was satisfied, with eight consecutive points (M3-M10) exceeding the pre-intervention median. At M9-M10, outside the active intervention period, attainment was 56.5% (36.8 percentage points above baseline). Within-physician analysis confirmed sustained improvement (Wilcoxon W = 7, p = 0.005; n = 13). The survey identified patient identification lists as the key facilitator, with carry-forward electronic medical record ordering and uncertainty about post-test management as primary barriers. Conclusions:An audit-and-feedback intervention achieved substantial and sustained improvement in urine testing QI attainment in nonspecialist primary care. Patient identification lists may have facilitated initial improvement, while sustained attainment may reflect behavioral routinisation.
Background:In Japan, both hospitals and outpatient clinics serve as primary care providers. However, the characteristics of primary care practices in hospitals and clinics, as well as the role and functions of primary care in mountainous and rural areas, are poorly understood. The purpose of this study was to identify the role and functions of primary care in small hospitals and outpatient clinics in mountainous areas, as well as the characteristics of primary care practices specific to these regions. Methods:A descriptive study was conducted between January and March 2024 at two municipal facilities in western Tottori Prefecture: Hino Hospital and Ebi Clinic. Adult patients who had received care in general medicine or general practice for more than six months were invited to complete the Japanese version of the Primary Care Assessment Tool (JPCAT). Results:Valid responses were obtained from 254 patients at Hino Hospital and 27 at Ebi Clinic, with response rates of 90.6% and 100%, respectively. First Contact scores were higher at Hino Hospital, while Community Orientation scores were higher at Ebi Clinic. Other domain scores showed broadly similar ranges. Conclusions:Differences in patterns of First Contact and Community Orientation were observed across the two facilities. These findings describe how primary care is perceived within a shared rural context and should not be interpreted as causal or generalizable differences between facility types.
ABSTRACT Background/Objective The transition from postgraduate residency to independent practice is a critical period prone to burnout. This longitudinal qualitative study explores the underlying drivers of burnout and its protective factors among early‐career physicians in Japan during this transitional phase. Methods At an urban Japanese hospital, seven residents completed semi‐structured interviews at the end of their protected two‐year basic postgraduate clinical training (2020) and again after transitioning to specialty training (2022); one further resident provided only partial information. Twelve senior physicians responsible for resident education and support center staff were interviewed for triangulation. Data were analyzed using grounded theory techniques with NVivo 14. Results No participant described experiences consistent with burnout during basic postgraduate clinical training, as residents perceived their environment as highly protected, often reporting a lack of primary responsibility and a passive “guest‐like” behavior rooted in the Japanese cultural desire to remain “good students.” However, follow‐up interviews revealed that the abrupt transition to independent practice exposed them to heavy responsibilities and complex patient management; burnout‐like episodes after the transition were described by some participants. Overcoming manageable challenges with adequate support was described as contributing to professional growth. Peer communication and continuous mentoring were vital mitigating factors. Conclusion Burnout‐like experiences among early‐career physicians appear to be driven mainly by the abrupt shift in clinical responsibility during the transition to independent practice rather than the absolute workload during initial training. Medical education programs should consider structured “graduated autonomy” and continuous mentoring to support this vulnerable transition.
ABSTRACT Background As populations age, older adults with type 2 diabetes and comorbid dementia are increasing. Dementia can impair diabetes self‐management and require physicians to reconsider treatment goals, family involvement, care coordination, and ethical decision‐making. However, few studies have explored physicians' specific challenges in such cases, particularly within the Japanese healthcare context. Methods This qualitative study examined physicians' perceived difficulties in caring for older adults with type 2 diabetes and dementia. Semi‐structured interviews were conducted with six primary care physicians and six diabetes specialists in Japan. Transcripts were analyzed using the Steps for Coding and Theorization (SCAT) method to identify recurring themes and compare perspectives across physician groups. Results Both groups reported challenges related to the gap between ideal and feasible care, dementia‐related disruption of self‐management, family involvement, emotional burden, and practical treatment adaptations. Primary care physicians more often emphasized preserving dignity, life context, longitudinal relationships, and coordination with other professionals. Diabetes specialists more often emphasized disease‐specific uncertainty, treatment‐goal adjustment, dementia diagnosis or disclosure, and pragmatic adaptations to maintain safety. Conclusions Physicians caring for older adults with type 2 diabetes and dementia experience clinical, ethical, relational, and emotional challenges shaped by their roles and practice contexts. These findings highlight the need for educational and organizational support to help physicians negotiate individualized treatment goals, family involvement, and interprofessional coordination in diabetes–dementia care. Future research should evaluate whether such support can reduce physician burden and improve care quality.
ABSTRACT This scoping review aimed to map the characteristics of dysphagia screening implementation in published studies and to compare operational differences between non‐Japanese and Japanese practices, focusing on screening personnel, screening tools, and post‐screening management pathways. Following the Joanna Briggs Institute methodology and PRISMA‐ScR guidelines, PubMed, Cochrane Library, CINAHL, and Ichushi‐Web were searched for studies published between 2016 and 2025 that described the clinical implementation of dysphagia screening. Twenty‐nine studies from 12 countries were included. In all 21 non‐Japanese studies, nurses performed screening using a single validated tool, with referral to speech‐language therapists for comprehensive evaluation. Japanese studies (n = 8) demonstrated variability, with screening conducted by nurses (n = 3), speech‐language therapists (n = 3), and physicians (n = 2), who frequently use multiple test combinations. Only 2 of 8 Japanese studies documented referral pathways for comprehensive evaluation following positive screening. Non‐Japanese studies consistently implemented structured screening‐to‐evaluation pathways, whereas Japanese studies demonstrated variability in screening personnel and limited documentation of post‐screening referral processes, resulting in blurring of the conceptual distinction between triage and diagnostic evaluation. As Japan's broader screening approach extends beyond the high‐risk populations targeted internationally, establishing standardized post‐screening pathways with clear role delineation becomes essential to maintain screening quality and optimize resource allocation in aging populations.
ABSTRACT A 69‐year‐old man presented with recurrent vertigo triggered by positional changes, left aural fullness, and left hemifacial spasm. The supine roll test showed direction‐changing apogeotropic horizontal nystagmus lasting < 1 min. Brain MRI demonstrated neurovascular contact between the cranial nerve VII/VIII complex and the anterior inferior cerebellar artery. Carbamazepine 200 mg/day achieved complete symptom resolution within 2 weeks and remission at 6 months. This report describes vestibular paroxysmia presenting with nystagmus resembling that observed in benign paroxysmal positional vertigo and, to our knowledge, represents the first report of direction‐changing apogeotropic horizontal nystagmus in this disorder.
Background:Advances in treatment have improved the survival rates of childhood cancer, which could make long-term health management (LTHM) a critical challenge. We aimed to identify challenges and perspectives associated with building a collaborative system between pediatric oncologists (POs) and general physicians (GPs) for LTHM of childhood cancer survivors (CCS). Methods:This qualitative study was conducted as part of a regional initiative in Fukushima, Japan aimed at establishing a community-based collaboration model between a university hospital-based specialized center and local GPs. We performed a thematic analysis of focus group discussions involving seven GPs and three POs to identify professional perspectives and barriers for future collaboration. Results:Three primary themes were identified. First, GPs recognized their potential to contribute by leveraging daily experience in multidisciplinary community networks, yet they acquired a deeper understanding of survivorship-specific psychosocial needs and clear consultation channels with POs. Second, POs maintained a strong sense of responsibility for lifelong care but harbored anxieties regarding care discontinuity, which were linked to structural problems, including undefined professional roles and the lack of robust information-sharing mechanisms. Third, both groups identified that the deep emotional bonds formed among CCS, families, and POs could hinder the involvement of new healthcare providers. Conclusions:Establishing a collaborative system requires bridging knowledge gaps regarding specific needs for CCS, and implementing structural improvements (e.g., clearly defined roles and effective information-sharing systems). Integrating these changes together with the values of patients and their families is essential for sustainable long-term care for CCS in the Japanese healthcare system.
