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Background The primary symptoms in the early stages of anti-NMDA receptor encephalitis are psychiatric manifestations, making it difficult to distinguish from psychiatric disorders. While anti-NMDA receptor encephalitis requires a completely different treatment approach, the specific psychiatric features of the condition remain poorly identified. Although previous studies have suggested that altered perceptions may be characteristic, few case reports focus on altered perceptions of time or time distortion, a phenomenon closely linked to NMDA receptor dysfunction as seen in individuals using NMDA receptor inhibitors like ketamine and phencyclidine. In this report, we describe two cases of anti-NMDA receptor encephalitis manifesting pronounced time distortion in its early stages, which may serve as diagnostic clues for the early diagnosis and treatment of this potentially lethal condition. Case presentations Two cases of Anti-NMDA receptor encephalitis, both marked by significant time distortion in the early stages and showing near-complete recovery with immunotherapy, are presented in detail. In both cases, time distortion was the predominant symptom among the psychiatric manifestations. Case 1: A middle-aged man experienced a pronounced perception of time moving 100 times slower in the early stages, accompanied by feelings of detachment and auditory abnormalities. This time distortion persisted for over a year, even after other symptoms had fully resolved. Case 2: A young woman reported that time seemed to move two to three times slower in the early stages. Although she did not initially mention time distortion, she confirmed it when specifically questioned. Conclusions Our report suggests that time distortion, particularly the perception of time moving slowly, can be a distinguishing feature in the early stages of anti-NMDA receptor encephalitis. This unique characteristic, especially when occurring independently of other symptoms, is rare as a primary and isolated symptom in other conditions, making it useful for differentiation from time distortion in other psychiatric disorders. Additionally, since some patients may not spontaneously report time distortion, actively assessing this symptom during early evaluation could help improve diagnostic accuracy.

A 71‐year‐old woman who, 27 years previously, had undergone left mastectomy and received postoperative hormone therapy for 1 year for breast cancer without recurrence, noticed a mass in her left supraclavicular fossa. The mass was approximately 5 cm in diameter. A biopsy confirmed the presence of metastatic breast cancer.

Attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are associated with attentional impairments, with both commonalities and differences in the nature of their attention deficits. This study aimed to investigate the neural correlates of ADHD and ASD traits in healthy individuals, focusing on the functional connectivity (FC) of attention-related large-scale brain networks (LSBNs). The participants were 61 healthy individuals (30 men; age, 21.9 ± 1.9 years). The Adult ADHD Self-Report Scale (ASRS) and Autism Spectrum Quotient (AQ) were administered as indicators of ADHD and ASD traits, respectively. Performance in the continuous performance test (CPT) was used as a behavioural measure of sustained attentional function. Functional magnetic resonance imaging scans were performed during the resting state (Rest) and auditory oddball task (Odd). Considering the critical role in attention processing, we focused our analyses on the default mode (DMN), frontoparietal (FPN), and salience (SN) networks. Region of interest (ROI)-to-ROI analyses (false discovery rate < 0.05) were performed to determine relationships between psychological measures with within-network FC (DMN, FPN, and SN) as well as with between-network FC (DMN-FPN, DMN-SN, and FPN-SN). ASRS scores, but not AQ scores, were correlated with less frequent commission errors and shorter reaction times in the CPT. During Odd, significant positive correlations with ASRS were demonstrated in multiple FCs within DMN, while significant positive correlations with AQ were demonstrated in multiple FCs within FPN. AQs were negatively correlated with FPN-SN FCs. During Rest, AQs were negatively and positively correlated with one FC within the SN and multiple FCs between the DMN and SN, respectively. These findings of the ROI-to-ROI analysis were only partially replicated in a split-half replication analysis, a replication analysis with open-access data sets, and a replication analysis with a structure-based atlas. The better CPT performance by individuals with subclinical ADHD traits suggests positive effects of these traits on sustained attention. Differential associations between LSBN FCs and ASD/ADHD traits corroborate the notion of differences in sustained and selective attention between clinical ADHD and ASD.

There has been growing interest in generalists in Japan in recent years. However, due to the diverse use of the term \"generalist\", the specific roles of these physicians remain ambiguous. Consequently, the target population for research on generalists is unclear, making it challenging to conduct studies within the generalist practice framework. Therefore, a literature search was conducted to examine how generalists are defined and classified in research worldwide. We conducted a literature search that focused exclusively on articles written in English and used keywords related to generalists, general medicine (GM), primary care, and family medicine. Based on the results, six physicians working in GM reviewed the findings and discussed the identified issues and their potential solutions. The definition of generalists in studies targeting GM, family medicine, and primary care conducted worldwide, including Japan, varies. Generalists exhibit diverse roles even within university hospitals in Japan. No studies provide a precise categorization or definition of generalists based on specific medical practices or roles, except for hospitalists, who are primarily involved in inpatient management in the United States. The definition of GM was unclear based on the results of the literature search, and the lack of uniformity in backgrounds has rendered the target population unclear. Consequently, in healthcare settings where medical systems vary by country or region, evidence from studies targeting generalists cannot readily apply to actual practice. Clarifying generalists through an explicit definition based on clinical practice will allow for a more precise target population for research on generalists and enable the accumulation of evidence related to well-defined groups of generalists, contributing to the advancement of GM. Therefore, future research is required to develop new indicators to precisely classify and define generalists.

Acute disseminated encephalomyelitis can present with brainstem symptoms and bilateral symmetrical lesions in the basal ganglia. In such cases, differentiation from chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids syndrome is necessary.

A 7‐year‐old Japanese boy was diagnosed with coronavirus disease 2019. He developed intermittent fever and headache, and the symptoms improved by Day 3. However, he developed membranous desquamation without erythema or swelling on the right hand on Day 4, which improved without treatment. Because COVID‐19 can cause membranous desquamation regardless of severity, the general condition, vital signs, and other physical findings should be carefully confirmed in children to rule out complications of MIS‐C or Kawasaki disease.

Bedriddenness Rank (BR) and Cognitive Function Score (CFS), issued by the Ministry of Health, Labour and Welfare, Japan, are easy-to-use and widely used in the medical and long-term care insurance systems in Japan. This study aims to clarify the criterion-related validity of the CFS with the Mini-Mental State Examination (MMSE) and ABC Dementia Scale (ABC-DS), and to re-evaluate the criterion-related validity of BR with the Barthel Index (BI) or Katz Index (KI) in more appropriate settings and a larger population compared with the previous study. A single-center prospective observational study was conducted in an acute care hospital in a suburban city in Japan. All inpatients aged 20 years or older admitted from October 1, 2018 to September 30, 2019. The relationship between BR and the BI and KI, and the relationship between CFS and the MMSE and ABC-DS were analyzed using Spearman's correlation coefficients. We enrolled 3,003 patients. Of these, 1,664 (56%) patients exhibited normal BR. The median (interquartile range) values of the BI and KI were 100 (65-100) and 6 (2-6), respectively. Spearman's rank correlation coefficients between BR and the BI and KI were -0.891 (p < 0.001) and -0.877 (p < 0.001), respectively. Of the patients, 1,967 (65.5%) showed normal CFS. The median (interquartile range) MMSE of 951 patients with abnormal CFS and ABC-DS of all patients were 15 (2-21) and 117 (102-117), respectively. Spearman's rank correlation coefficients between CFS and MMSE and ABC-DS were -0.546 (p < 0.001) and -0.862 (p < 0.001), respectively. BR and CFS showed significant criterion-related validity with well-established but complicated objective scales for assessing activities of daily living and cognitive functions, respectively. These two scales, which are easy to assess, are reliable and useful in busy clinical practice or large-scale screening settings.

Key Clinical Message When seeing patients who present with atypical lymphocytes and abdominal pain without accompanying symptoms of pharyngitis or lymphadenopathy, acalculous cholecystitis caused by CMV infection should be considered as a differential diagnosis. A teenage man presented with a fever and epigastric pain. The patient tested positive for cytomegalovirus IgG and IgM. Abdominal ultrasonography and contrast‐enhanced CT revealed hepatosplenomegaly and gallbladder wall thickening. MRI did not identify gallstones or tumorous lesions. He was diagnosed with infectious mononucleosis and acalculous cholecystitis caused by cytomegalovirus.

A woman in her 70s with schizophrenia experienced repeated episodes of limb tremors and hypoxemia. Even after admission, the same symptoms continued while in a supine position. However, her condition rapidly improved with bag valve mask ventilation. Although computed tomography suggested aspiration pneumonia, she had a strong cough reflex while performing bronchoscopy, and no residues were observed in the trachea. Following the bronchoscopy examination, the patient was prompted by a nurse and subsequently expelled a mass of watermelon from her oral cavity, which was identified as a watermelon eaten during breakfast on the day. She was diagnosed with aspiration pneumonia, and treatment with 2 g/day of cefotiam was initiated. The inflammatory response had improved, and she was transferred to another hospital for adjustment of psychiatric medications on the 10th day of admission. A study indicated that 77% of emergency medical staff experienced misdiagnosis or delayed diagnosis of patients with mental illnesses. In the present case, various biases and system factors were found to be involved in the diagnostic error. It is crucial to recognize the potential for diagnostic errors in managing patients with schizophrenia given the various biases that may come into play. Furthermore, patients with schizophrenia are at high risk of upper airway foreign body obstruction because of dysphagia or drug-induced effects. When transient hypoxemia is observed, a prompt assessment of the visible intraoral region and, if necessary, evaluation of the entire upper airway through imaging studies should be considered.

Clinical physicians have the potential to contribute to the progress of medicine and healthcare through research based on their diagnostic and treatment practices and supported by their educational background. However, in the field of general medicine in Japan, publication of such research in international journals may be limited by challenges in English proficiency and the lack of opportunities to focus on specific research themes amidst the diverse range of diseases treated in clinical practice. Furthermore, novice researchers without prior research experience may lack a comprehensive understanding of the overall research process, including study design and article publication. To address these challenges, we developed a set of 22 milestones that highlight the necessary skills required to conduct and successfully publish clinical research. This guideline will enable novice researchers to identify and address individual barriers to undertaking a research project. These milestones are categorized into five parts: 1) preparing to undertake research; 2) conducting clinical research; 3) writing the article; 4) submitting and achieving acceptance for publication; and 5) advanced skills. For each part, we provide detailed recommendations on the specific steps and methods involved. By working through these 22 milestones, novice researchers can objectively assess their own level of achievement as researchers and continuously clarify the next step of each round of research. Through this set of milestones, we aim to increase the quality and quantity of research publications in general medicine in academic journals, ideally enhancing the overall research process and advancing the field of medicine and healthcare overall.