Cognitive apprenticeship and reflective practice are fundamental educational theories supporting postgraduate clinical training. Community hospital rotations provide ideal opportunities to apply these theories. However, community hospitals face challenges in securing educational time due to faculty shortages and heavy clinical workloads, leading to on-the-job training becoming the primary educational approach. Consequently, opportunities for structured instruction and reflection may be limited, potentially hindering the implementation of cognitive apprenticeship and reflective practice. To address this mismatch between educational needs and available resources, we implemented a remote educational conference focused on clinical questions (CQs) arising from residents' clinical experiences. Unlike traditional clinical conferences that focus on determining patient management, this initiative centers on reflective dialogue based on CQs formulated by residents themselves. By integrating experiential learning theory and reflective practice theory and focusing specifically on the latter three steps of cognitive apprenticeship, we successfully constructed an effective educational model for remote learning environments. This practice enables high-quality medical education that transcends geographical constraints and is considered valuable for future community-based medical education.

A unified consensus statement on medication-related osteonecrosis of the jaw (MRONJ) has not yet been established among the Asian member countries or regions of the Asian Federation of Osteoporosis Societies (AFOS). This study aimed to develop a consensus on MRONJ in patients with osteoporosis across these countries and regions. In this study, the term “Asia-Pacific” refers specifically to the Asian member countries and regions of AFOS. A structured survey consisting of nine MRONJ-related questions was distributed across 10 countries and regions to assess the level of agreement and summarize regional perspectives. In addition, a manual literature review and voting were conducted to evaluate the current evidence on MRONJ. The key aspects of MRONJ, including definition, staging, diagnosis, pathogenesis, risk factors, management, and prevention, were generally consistent among the AFOS countries and regions. The annual incidence and incidence rate of MRONJ associated with low-dose antiresorptive therapy in patients with osteoporosis ranged from 0.025% to 0.136% and 21 to 283 cases per 100,000 person-years, respectively. However, evidence regarding the benefits of drug discontinuation before dental surgery, such as tooth extraction, remains insufficient. Large-scale, multinational studies across AFOS countries and regions are warranted to determine the incidence of MRONJ better and evaluate the impact of antiresorptive drug discontinuation before dental procedures. These findings may contribute to the devel opment of effective evidence-based strategies for preventing MRONJ in patients with osteoporosis.

Background: Vertebral compression fractures (VCFs) are associated with reduced gait ability and functional impairment in older adults. Factors related to walking aid use at discharge remain unclear. This study examined associations between walking aid use and physical function at discharge. Methods: This cross-sectional study included 143 patients with VCFs discharged from Kurume Rehabilitation Hospital. Participants were classified into independent ambulation and walking aid groups, the latter subdivided into cane and walker users. Pain, cognitive function, handgrip strength, 30-second chair stand test, Berg Balance Scale (BBS), and skeletal muscle mass index (SMI) were assessed at discharge. Logistic regression identified factors associated with walking aid use, and exploratory analysis compared cane and walker users. Receiver operating characteristic (ROC) analysis was used to determine the BBS cutoff. Results: BBS at discharge was significantly associated with walking aid use (odds ratio [OR]=0.85; 95% confidence interval [CI] 0.77–0.93; p<0.001). In exploratory analysis, pain (OR=1.43; 95% CI 1.03–1.96; p=0.029) and SMI (OR=0.40; 95% CI 0.20–0.79; p=0.010) were associated with cane versus walker use. The optimal BBS cutoff was 48.5 (area under the curve [AUC]=0.83). Conclusion BBS was associated with the distinction between independent ambulation and walking aid use, while pain and SMI were associated with differences among walking aid users. These findings may inform clinical decision-making for walking aid selection at discharge.

Purpose: Surgical resection of remnant gastric cancer (RGC) is technically challenging and difficult. Minimally invasive surgery (MIS) has been adopted for various procedures, but reports of MIS for RGC remain limited. Herein, we report the surgical techniques and short-term outcomes of MIS for RGC. Methods: We conducted a retrospective cohort study involving 61 consecutive RGC patients who underwent open or minimally invasive (laparoscopic or robotic) total gastrectomy for potentially curable RGC at our institution (January 1999–August 2025). A propensity scorematched cohort was used for an exploratory evaluation of the safety and efficacy of MIS for RGC, focusing on feasibility rather than superiority over open surgery. Results: Of these 61 patients, 53 underwent open surgery and eight underwent MIS gastrectomy for RGC. The median age was 70 years. The cohort comprised 53 men and eight women. The initial procedure was open surgery in 58 patients and MIS in three patients.Propensity score matching showed significantly reduced intraoperative blood loss in the MIS group compared with the open surgery group (39 mL vs. 576 mL, p < 0.05), and significantly longer operation time in the MIS group (352 minutes vs. 297 minutes, p < 0.05). Postoperative hospital stay was significantly shorter in the MIS group (12 days vs. 17 days, p < 0.05). The incidence of postoperative pancreatic fistula was lower in the MIS group, although not significantly different (0% vs. 16.7%). Conclusion MIS, including robotic gastrectomy, is feasible and safe for RGC, with potential perioperative benefits requiring multicenter validation.

Methods: Lateral radiographs were obtained from 100 healthy adults in standing and seated postures at 25°, 35°, and 45° recline angles. Spinal parameters (cervical lordosis, thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and T1 spinopelvic inclination) and seat belt metrics (X-value, Z-value, and lap belt angle) were measured. Multivariate regression was used to assess associations with sex, age, height, and body mass index (BMI). Results: Reclining reduced cervical/lumbar lordosis and sacral slope, while thoracic kyphosis and pelvic tilt increased. Higher BMI was associated with a cranially shifted and more horizontal lap belt. Taller individuals showed greater T1 spinopelvic inclination and pelvic parameters. Females exhibited more pronounced thoracic kyphosis and pelvic retroversion across reclining angles. Conclusions Car seat recline significantly alters spinal alignment and seat belt positioning, with changes influenced by age, height, and BMI. These findings support ergonomic improvements in seat design and may inform surgical planning for ASD.

Methods: We analyzed data from 101 patients who underwent spinopelvic surgery involving 202 S2AI screws. Postoperative computed tomography (CT) images were reviewed to identify screw deviations. The reconstructed fluoroscopic views from CT, including the inlet, OI, and IO views, were assessed for their effectiveness in detecting deviations. An experimental study using pelvic bone models simulated scenarios where deviations were undetectable in the inlet view but visible in the OI view. Results: Screw deviations were identified in 12 cases (11.9%) and 13 screws (6.4%), including six screws (3.0%) with anterior deviations and seven screws (3.5%) with posterior deviations. The accurate inlet view detected anterior deviations in three of the five cases analyzed with reconstructed images. However, two cases of anterior deviation were missed due to an insufficient inlet view caused by a 30° caudal tilting angle. In contrast, the OI view successfully identified all cases of both anterior and posterior deviations. In particular, deviations above the arcuate line of the pelvic brim were not detectable in the inlet view. Conclusions The inlet view alone is inadequate for detecting anterior deviations, especially those located above the arcuate line of the pelvis. The OI and IO views demonstrated greater effectiveness in identifying deviations, thereby enhancing the accuracy and safety of S2AI screw placement.

Purpose: Adjuvant pembrolizumab improved disease-free survival (DFS) and overall survival (OS) versus placebo in participants with renal cell carcinoma (RCC) at increased risk of recurrence after nephrectomy in the global phase 3 KEYNOTE-564 study. This post hoc subgroup analysis evaluated the efficacy and safety of adjuvant pembrolizumab in East Asian (Japan, South Korea, and Taiwan) participants enrolled in KEYNOTE-564. Materials and Methods: Eligible participants were randomly assigned 1:1 to receive adjuvant pembrolizumab 200 mg or placebo intravenously every 3 weeks for ≤ 17 cycles. The primary endpoint was DFS by investigator assessment. OS was a key secondary endpoint. Safety was a secondary endpoint. Results: The East Asian subgroup included 126 participants (pembrolizumab, n=58; placebo, n=68). Median follow-up was 62.1 months (range, 49.6 to 73.0 months). Hazard ratio for DFS with pembrolizumab versus placebo was 0.70 (95% confidence interval 0.41 to 1.20). Median DFS was not reached with pembrolizumab versus 58.8 months with placebo; estimated 48-month rate was 61.3% versus 51.2%. Hazard ratio for OS was 0.47 (95% confidence interval, 0.15 to 1.49). Median OS was not reached with pembrolizumab and placebo; estimated 48-month rate was 94.8% versus 91.2%. Treatment-related adverse events occurred in 70.7% of participants (29.3% grade 3 or 4) receiving pembrolizumab and 36.8% of participants (0.0% grade 3 or 4) receiving placebo. No pembrolizumab-related deaths occurred. Conclusion In the KEYNOTE-564 East Asian subgroup, adjuvant pembrolizumab provided DFS and OS benefits versus placebo and had a safety profile consistent with the global results. These results further support pembrolizumab as adjuvant treatment for East Asian patients with RCC at increased risk of recurrence after nephrectomy.

It is extensively documented that tumor hypoxia contributes to the failure of chemotherapy and radiotherapy. Recent evidence suggests that hypoxia is also closely involved in the resistance to immunotherapy. In this review, we highlight how immune cells that are essential for the maximized immunotherapy efficacy, including cytotoxic T cells, dendritic cells, and natural killer cells, can adapt to tumor hypoxia. We then outline previous attempts targeting tumor hypoxia (for example, modulators of tumor cell oxygen consumption, perfusion modulators, hypoxia-activated prodrugs, hypoxia-inducible factor inhibitors, and hypoxia-responsive chimeric antigen receptor T cells) discussing how these approaches have resulted in an improvement of the antitumor response to immunotherapy in preclinical or clinical settings. Lastly, we review various non-invasive techniques to detect the tumor hypoxia and immune responses. We believe that an integration of the biological knowledge of immune cell adaptation to tumor hypoxia with the cutting edge non-invasive imaging technologies may ultimately allow us not only to select for patients who would benefit the most from the immunotherapy but also to monitor their responses in a real-time manner so that we can offer them an optimal personalized medicine in the clinic.