Mucormycosis is a severe infection that requires prompt antifungal therapy. Although liposomal amphotericin B (L-AMB) is the standard treatment, its toxicity may limit its use. We report the case of a patient with diabetes mellitus and rhinocerebral mucormycosis who developed brain abscesses despite L-AMB and surgical interventions. After switching to isavuconazole (ISCZ) and continuing surgical management and optimization of underlying conditions, clinical and radiological improvements were observed. Although partial maxillary bone loss occurred during follow-up, the ISCZ was continued for more than one year without adverse events, and the patient remained clinically stable. Notably, although the isolate showed an ISCZ MIC >8 μg/mL, a clinical improvement was observed with multidisciplinary management.

Abstract Background Infective endocarditis (IE) remains a diagnostically challenging disease with diverse symptoms. Whether IE is suspected frequently depends on clinical judgement. A reliable model to estimate the likelihood of IE at presentation across clinical departments is needed; however, no such model is currently available. We aimed to develop such a diagnostic prediction model using objective and reproducible variables and to validate its performance. Methods We included inpatients aged ≥ 20 years who had either a diagnosis code for IE or for undiagnosed fever during hospitalization. The model was developed using data from a single university hospital between 2007 and 2017 (derivation cohort) and validated with data from four university hospitals between 2018 and 2020 (validation cohort). IE was diagnosed according to the 2023 Duke-International Society for Cardiovascular Infectious Diseases (ISCVID) criteria. Variables were selected using the Boruta algorithm and Least Absolute Shrinkage and Selection Operator regression. Multivariable logistic regression analysis was used to estimate odds ratios and 95% confidence intervals and to construct the model. Model performance was assessed in both cohorts using the area under the curve (AUC). In the validation cohort, calibration was also assessed using the calibration slope, Hosmer–Lemeshow test, and stratified likelihood ratio. Results The derivation and validation cohorts included 105 (46 IE) and 286 (106 IE) patients, respectively. Predictors in the final model were the presence of a cardiac murmur, log-transformed platelet count, neutrophil percentage, presence of pleural effusion, and a quick sequential [sepsis-related] organ failure assessment score ≥ 2. The AUC was 0.918 in the derivation cohort. In the validation cohort, the AUC was 0.859, with a Hosmer– Lemeshow test p-value of 0.246 and a calibration slope of 0.759. The stratified likelihood ratio ranged from 0.04 to 9.71 and increased with higher model scores. Conclusions This model showed high discrimination and good calibration using objective variables that are readily available early after admission. Furthermore, this is the first model to predict IE based on the 2023 Duke-ISCVID criteria. Further multicenter validation in community hospitals would enhance generalizability.

BACKGROUND:While PSA screening reduces prostate cancer (PCa) mortality, it is associated with overdiagnosis and unnecessary biopsies. Breathomics presents a painless, repeatable adjunct method, provided that robust volatile biomarkers can be reliably identified. OBJECTIVE:To evaluate whether targeted quantification of 12 biologically plausible aldehydes in end-tidal breath can differentiate histologically confirmed PCa from biopsy-negative or low-PSA control subjects. METHODS:In a prospective exploratory study at Toho University Omori Medical Center (Tokyo, Japan), we enrolled men aged ≥50 years between 1 September 2020 and 31 August 2023. Breath samples, obtained after an overnight fast, were derivatised with O-(2,3,4,5,6-pentafluorobenzyl)-hydroxylamine and analysed using conventional quadrupole GC/MS. Limits of detection ranged from 0.3 to 1.1 ng. Non-detects were addressed using LOD/2 substitution and Tobit left-censored regression. Group differences were assessed using two-tailed Wilcoxon or Fisher's exact tests (α = 0.05). Ethics approval: M16243 / M20229; informed consent was obtained. RESULTS:Thirty-three men were analysed (PCa = 22; controls = 11). Only formaldehyde and acetaldehyde were quantifiable in ≥85% of samples. Median concentrations did not differ (formaldehyde: 3.09 [2.15-5.35] vs. 5.85 [2.72-7.36] ng , p = 0.181; acetaldehyde: 7.47 [5.36-11.73] vs. 7.80 [6.70-14.32] ng, p = 0.456). The exploratory formaldehyde-to-acetaldehyde ratio was likewise non-discriminatory (p = 0.87). The remaining ten aldehydes showed detection rates ≤45.5% and no significant group differences in Tobit modelling. CONCLUSIONS:Single-compound aldehyde profiling with PFBHA-GC/MS failed to differentiate PCa from controls, primarily due to low analyte detection rates and minimal between-group contrasts. Enhanced-sensitivity platforms (e.g., GC×GC-HRMS or MEMS-based pre-concentrators) and multi-component VOC signatures coupled with rigorous control of smoking and ambient confounders are needed before breath testing can contribute meaningfully to prostate cancer screening.

Neuroleptic malignant syndrome (NMS) can be complicated by rhabdomyolysis, a known cause of acute kidney injury (AKI) that typically resolves within a short period. However, some cases of NMS-associated rhabdomyolysis require hemodialysis. We report a woman in her fifties who developed AKI secondary to NMS-associated rhabdomyolysis and required prolonged renal replacement therapy (RRT). She experienced sepsis and contrast exposure, and dialysis independence was achieved only after 2 months, the longest reported duration. This case highlights that NMS-associated rhabdomyolysis-induced AKI may lead to prolonged dialysis, particularly in the presence of additional risk factors for renal injury.

Outpatient care is among the most complex and essential domains of general medicine physicians in Japan. Physicians must diagnose, treat, provide patient education, and implement preventive care within a limited time period. Despite its importance, outpatient education has historically received less emphasis than inpatient training. At the 31st Annual Meeting of the Japanese Society of Hospital General Medicine, a symposium was convened to explore the educational challenges and strategies in outpatient practice, highlighting three key themes. First, to ensure safety and quality, learners should be trained to prevent omissions in diagnostic labeling, perform severity assessments and triage, and attend to subtle impressions of “something is not right” reported by patients and families. Second, addressing diagnostic challenges requires structured reasoning frameworks, awareness of patient complexity, strategies to suspect rare diseases, skills to communicate diagnostic uncertainty, persistence through non-abandonment and grit, and effective specialist consultations. Third, managing chronic diseases and providing preventive care necessitate active intervention in polypharmacy, application of structured deprescribing approaches, use of multidisciplinary teams, and implementation of individualized care plans introduced as a tool for patient-centered behavioral change. Strengthening outpatient education in these areas will enhance learner competence and contribute to safer, higher-quality, patient-centered healthcare in Japan.

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but may induce immune-related adverse events (irAEs), including rare neuromuscular toxicities such as myositis. Because of its low incidence (≤ 0.5%), ICI-related myositis is often under-recognized, especially when presenting with nonspecific prodromes like isolated fever. We report a 64-year-old man who developed ICI-related myositis six weeks after initiating pembrolizumab plus enfortumab vedotin for urothelial carcinoma. Fever preceded myalgia and dysphagia by about two weeks, leading to evaluation for fever of unknown origin. Magnetic resonance imaging revealed diffuse thigh muscle hyperintensity. Infection, paraneoplastic myositis, and drug-induced myopathy were excluded. High-dose corticosteroid therapy achieved rapid improvement and sustained remission. This case highlights that ICI-related myositis can initially manifest solely as fever, delaying recognition. Clinicians should maintain a high index of suspicion for myositis in patients receiving ICIs who develop unexplained fever, even in the absence of weakness or rash. Differentiation from paraneoplastic and other myopathies requires attention to timing, clinical course, MRI findings, and autoantibody profiles. Bulbar involvement, such as dysphagia, signals severe disease and warrants prompt intensive therapy. Early diagnosis through vigilant bedside assessment and, when feasible, muscle biopsy is essential to improve outcomes in this uncommon but potentially fatal irAE.

In Japan, hospital-based general medicine physicians play a significant role in outpatient care. Outpatient practice demands advanced clinical skills, including the swift recall of differential diagnoses, effective patient communication, and the implementation of comprehensive management plans. Based on these demands, we developed five key themes for enhancing the quality and efficiency of outpatient care. The themes were derived from discussions at the Japan Society of Hospital General Medicine Annual Meeting, where physicians exchanged insights and identified practical approaches to common outpatient challenges. The five themes are: (1) history-taking and physical examination, emphasizing structured, patient-centered methods; (2) fostering patient-physician relationships to build trust and continuity; (3) ensuring continuity of care, particularly for patients with undiagnosed or medically unexplained symptoms; (4) balancing efficiency and quality improvement to manage complex patient cases in both inpatient and outpatient settings; and (5) preventing burnout, promoting resilience, and fostering “joy in patient interactions” for sustainable practice. This framework synthesizes concepts from patient-centered care, narrative medicine, and family medicine and reinterprets them for hospital generalists. By adopting these themes, Japanese hospital-based general medicine physicians can achieve improved patient outcomes and a more fulfilling clinical practice.

The evaluation of acute abdominal pain remains diagnostically challenging, particularly in adolescent females, where gynecologic and systemic causes must be considered. Immunoglobulin A vasculitis (IgAV) can initially manifest with isolated gastrointestinal symptoms, making early recognition difficult when the classical triad of purpura, arthritis, and abdominal pain is incomplete. We report a case of IgAV in a 16-year-old girl who presented solely with abdominal pain. Imaging showed terminal ileal thickening, but no definitive etiology. Continued inpatient observation and hypothesis-driven physical examination (HDPE) revealed new-onset purpura and arthritis on hospital day 8. A skin biopsy of the purpuric lesions confirmed the diagnosis, showing leukocytoclastic vasculitis with perivascular neutrophilic and eosinophilic infiltration on histology and IgA deposition on immunofluorescence. This case underscores the importance of HDPE and serial reassessment in diagnostically ambiguous cases of acute abdomen. Importantly, it highlights the diagnostic utility of skin biopsy in confirming vasculitis, particularly when extra-abdominal features appear late in the clinical course. Early discharge could have led to delayed or missed diagnosis. Clinicians should maintain vigilance for evolving systemic signs in similar presentations and be aware that purpura and arthritis may emerge only after a significant delay from the initial gastrointestinal symptoms.

Background Bloodstream infections (BSIs) caused by extended-spectrum β-lactamase-producingEnterobacterales (ESBL-E) are associated with increased morbidity and mortality, yet the optimal empiric treatment strategy remains uncertain. We aimed to identify prognostic factors for early clinical response and 30-day mortality in patients with ESBL-E bacteremia and to evaluate the impact of the appropriateness of empiric antimicrobial therapy. Methods We conducted a retrospective cohort study at a 916-bed tertiary care hospital in Tokyo, Japan, including all patients with ESBL-E bacteremia between April 2018 and March 2023. Clinical, microbiological, and therapeutic data were extracted from electronic medical records. Independent variables were selected based on prior literature, including age, sex, Charlson Comorbidity Index (CCI), quick sequential organ failure assessment (qSOFA) score, infection setting, invasive device use, C-reactive protein (CRP) level, and appropriateness of empiric antimicrobial therapy. Logistic regression was used to identify predictors of clinical improvement within 72 hours and 30-day all-cause mortality. Results A total of 138 patients were included, with a median age of 72.7 years; 83% of infections were caused by Escherichia coli. The urinary tract was the most common source of infection (58%). Approximately half of the infections were hospital-acquired (49%), and 46% were community-acquired. Appropriate empiric therapy, defined according to Clinical and Laboratory Standards Institute (CLSI) criteria, was administered in 60% of cases. Logistic regression analysis revealed that a qSOFA score ≥2 was significantly associated with reduced clinical improvement at 72 hours (odds ratio (OR), 0.29; 95% confidence interval (CI), 0.11-0.76) and with increased 30-day mortality (OR, 9.42; 95%CI, 2.27-39.11). Conversely, community-acquired infection was independently associated with reduced mortality risk (OR, 0.25; 95%CI, 0.06-0.94). Appropriateness of empiric antimicrobial therapy was not significantly associated with either early clinical response or 30-day mortality in multivariable analysis. In subgroup analysis of patients with a qSOFA score ≥2, inappropriate empiric therapy tended to be associated with higher 30-day mortality (OR, 7.22; 95%CI, 0.74-107.88), though this did not reach statistical significance. Conclusion Among patients with ESBL-E bacteremia, a qSOFA score ≥2 at the time of blood culture collection was the strongest independent predictor of both poor early clinical response and higher 30-day mortality, regardless of empiric antimicrobial appropriateness. These findings suggest that patient severity at presentation may outweigh the impact of initial antimicrobial selection in determining outcomes. However, potential for clinical deterioration with inappropriate therapy in high-risk patients underscores the need for timely, effective empiric coverage in those with suspected sepsis and elevated qSOFA scores. Risk stratification using qSOFA may support tailored empiric therapy decisions, helping to balance effective patient care with antimicrobial stewardship. Prospective, multicenter studies are warranted to validate these results and refine treatment strategies in the era of increasing antimicrobial resistance.

Objective: The prevalence of acute hepatic porphyria (AHP) in Japan is unknown. To diagnose AHP, identifying populations with a high prevalence of AHP is essential. We focused on non-specific abdominal pain (NSAP); however, the criteria for NSAP vary across studies. Therefore, this study aimed to investigate the diagnostic process of undiagnosed abdominal pain in general medicine clinical practice before proposing a definition of NSAP. In addition, we aimed to examine the potential AHP-related symptoms and implementation of AHP testing in these patients. AHP is a rare but fatal and treatable disease; hence, its early diagnosis is essential. Design: This retrospective observational study was conducted in the general medicine departments of six medical institutions in Japan over a 3-year period beginning on April 1, 2019. Participants: Patients with abdominal pain who underwent abdominal imaging examinations were included. Main outcome measures: The primary outcome was to characterize patients with undiagnosed abdominal pain. In addition, this study aimed to identify situations where physicians attempt to diagnose AHP in patients with abdominal pain. Results: Of the 1915 eligible participants, 317 (16.6%) had undiagnosed abdominal pain, and none of them were diagnosed with AHP in diagnosed abdominal pain. The median patient age was 55 years, and 134 patients were male. Multivariate logistic analysis revealed that hospitalization, dull pain, and the absence of depressive symptoms were associated with abdominal pain. All patients with undiagnosed abdominal pain demonstrated two to four indicative symptoms of AHP. However, none underwent urinalysis for a definitive diagnosis of AHP. Conclusions: Depressive symptoms and the absence of dull pain were associated with undiagnosed abdominal pain. Hospitalization for examination contributed to improving the diagnosis of abdominal pain. Despite the presence of indicative symptoms, urinary markers for AHP diagnosis were not measured. Establishing a diagnostic strategy for undiagnosed abdominal pain would provide better opportunities for patients with NSAP and could help shorten the diagnostic journey for those with rare diseases such as AHP.

Purpose:General medicine physicians in Japan play diverse roles depending on their work environments; however, there is no clear definition. In the United States, the establishment of a definition for "hospitalists" has contributed to the accumulation of evidence. To develop research in general medicine and build evidence in Japan, there is an urgent need to establish a systematic classification method for general medicine physicians. Methods:Based on discussions with six hospital-based general medicine physicians with over 10 years of experience at an academic conference in 2024 and a literature review, we proposed a classification method for general medicine physicians. Results:The proposed classification method was based on four indicators: physician maldistribution index, inpatient care contribution index (the contribution of one general medicine physician to inpatient care across all beds in the hospital), clinical content (home medical care, outpatient care, emergency response, inpatients management, and critical inpatients management), and education (medical students, clinical residents, and senior residents). These indicators were established by considering physician characteristics, target population, social environment, and hospital environment, enabling an objective evaluation of factors contributing to the practice of general medicine physicians. Conclusion:This classification method may serve as a foundation for research that makes it easier to understand the characteristics of general medicine physicians under study and allows for the comparison of roles according to regional characteristics and hospital size. Future validation and continuous improvement of this classification method are expected to advance the accumulation of evidence related to general medicine physicians. In this paper, we present a proposal for a classification method; future validation of this classification is necessary.

Invasive group A streptococcal infection (iGAS) can develop rapidly in immunocompromised individuals. We describe the case of a 66-year-old man with multiple myeloma who was admitted for chemotherapy and subsequently developed iGAS. He had been performing nasal self-packing with facial tissue for nasal discharge and hemorrhage. During hospitalization, he developed erythema, pain, and swelling around the nose and experienced a sudden onset of septic shock characterized by profound hypotension requiring norepinephrine infusion. Streptococcus pyogenes was detected in blood cultures, and treatment with beta-lactam antibiotics and clindamycin led to rapid improvement. Follow-up testing revealed that emm typing identified the strain as emm49. This case highlights that in immunocompromised individuals, trivial self-care like nasal self-packing can precipitate severe infections such as iGAS and shock, emphasizing the need for clinical vigilance.

General medicine was formally established as a basic specialty in Japan in 2018, and a specialty program for hospital general medicine was later launched in 2022. Fellows of Hospital General Medicine (FHGM) are expected to deliver high-quality care in outpatient clinics, general beds, emergency wards, and intensive care settings while contributing to community healthcare, research, and education. However, the number of FHGMs remains small, with key challenges regarding education and career path clarification. Educational improvement requires clinical supervision by experienced FHGMs and enhanced diagnostic reasoning education through a well articulated teaching regimen.Additionally, presenting clear FHGM career paths is essential, as it requires concrete, diversified career models and network building. Such systems are necessary to continuously train FHGMs to provide standardized, high-quality medical care and to contribute to the dissemination and expansion of the Japanese healthcare system.

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.