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Abstract The time series of PALSAR-2 and Sentinel-1 images reveal inflation at the volcanic flank and contraction at the crater for approximately 5 months before the 2017 eruption of Shinmoe-dake volcano, Japan. While the observation of inflation at the volcano’s flank is ubiquitous, few studies have reported crater contraction preceding an eruption. The flank inflation stopped after the 2017 eruption, while the contraction at the crater continued until the 2018 eruption. We found that a pipe-shaped deformation source above sea level best fits the observation preceding the 2017 eruption. Suppose the flux of ejected materials constrains the conduit radius during the previous 2011 eruption. In that case, the amount of deformation of the pipe-shaped deformation source, whether open or closed at its top, is too large to be realistic. Although constraining the conduit radius from the eruption flux overestimates the pressure change of the pipe-shaped deformation source, water-saturated fractures along the volcanic conduit could extend the effective conduit radius of the pressure source. We propose one potential scenario for the mechanism of the crater contraction preceding volcanic eruptions based on the combination of compaction due to cooling by ambient groundwater and material withdrawal within the conduit. The groundwater inflows from the ambient aquifer through cracks in the porous conduit wall, which are generated by conduit expansion during the magma ascent. Decoupling from the conduit wall due to a decrease in volume of the material promotes material instability and crater contraction. The interaction between the groundwater and the magma triggers the 2017 eruption of Shinmoe-dake volcano, as previous studies have reported. Graphical Abstract

Abstract The multipath effect is a major Global Navigation Satellite System (GNSS) error source due to its environment-dependent characteristic, which complicates its mitigation process for the high-rate determination of displacements. For instance, Sidereal Filtering (SF) and Multipath Hemispherical Map (MHM) require the observations spanning at least one full cycle of satellite orbit repeat period (e.g., ten days for Galileo navigation satellite system (Galileo) to reproduce the satellite geometry against ground stations. As a consequence, the practicability of SF and MHM is limited due to potential station-surrounding changes over a long period. In this study, we used the overlap-frequency signals on Global Positioning System (GPS) L1/L5, Galileo E1/E5a, and BeiDou-3 Navigation Satellite System (BDS-3) B1C/B2a to construct an interoperable MHM (i.e., MHM_GEC) across constellations to mitigate multipath more efficiently. We thus used 31 days of 1-Hz GPS/Galileo/BDS-3 data at 21 stations in Europe to compare this overlap-frequency MHM with those GNSS-specific MHMs (i.e., MHM_G for GPS, MHM_E for Galileo, and MHM_C for BDS-3), as well as SF. It is confirmed that the multipath effects on overlap-frequency signals are of a high spatial consistency across all GNSS. The mean reduction rate of applying MHM_GEC to GPS, Galileo, and BDS-3 carrier-phase residuals is 25%, 31%, and 28.5%, respectively, which are up to 25 percentage points higher than those of MHM_G, MHM_E, and MHM _C. Furthermore, the MHM_GEC constructed using 5 to 6 days of data can improve the positioning precision by 40%, outperforming the MHM_E, MHM_C, and SF using 10 days of data. Therefore, the interoperable MHM_GEC is more efficient in mitigating multipath effects for high-precision GNSS positioning.

Abstract Magmas, especially mafic ones, usually intrude into the upper crust as dikes. The intruded dike is often arrested before reaching the surface to make an eruption. Many geophysical observations, including geodetic measurements, have documented dike intrusions and arrests. Also, many theoretical considerations and analog experiments explored the mechanics of dike propagation and arrest. However, insights gained from theoretical considerations, analog experiments, and geophysical observations have yet to be well reconciled. This study attempts to reconcile geodetic measurements with insights gained from theoretical considerations and analog experiments to investigate how to forecast whether an intruded dike results in an eruption or not. This study considers four causes of dike arrests: (1) solidification of the intruded magma, (2) insufficient volume of dike intrusion, (3) negative buoyancy acting on the intruded magma, and (4) stress perturbation near the dike tip by a large earthquake. Then, this study investigates the cause of dike arrests associated with the 1997 and 1998 seismic swarm off the Izu Peninsula, Japan, and the 2015 failed eruption of Sakurajima volcano, Japan, as an example. This study suggests that the dike intrusions associated with the 1997 and 1998 seismic swarm off the Izu Peninsula are caused by insufficient volume of the dike, the loss of buoyancy, or both. The failed eruption of the 2015 Sakurajima eruption is most likely by insufficient volume. To investigate the contribution of geodetic data in understanding the cause of dike arrests, it is essential to consider the characteristics of geodetic data. They are: (1) geodetic data constrain the intruded volume and the location relatively well, (2) geodetic data cannot constrain the geometry of the intruded dike very well, (3) an assumption of the host rock as homogeneous halfspace underestimates the volume of the intruded dike and estimates the depth of the dike shallower than the true value. These limitations indicate that we cannot fully understand the cause of dike arrests solely from geodetic data. Independent information gained from, for example, the location of dike-induced earthquakes, seismic structures, or density structure from gravity anomalies or muon radiography helps better understand the cause of dike arrests. Graphical Abstract

Abstract The February 2023 Turkey‐Syria Earthquake doublet ruptured multiple segments of the East Anatolian Fault (EAF) Zone. Dominating seismicity focal mechanism shifted dramatically from strike‐slip to normal‐faulting after the doublet. To better understand this shift, here we derived a comprehensive 3D co‐seismic displacement field and performed the stress analysis. Abundant space geodetic data were used to generate high‐resolution 3D surface displacement, which provide tight constraints on fault geometry, slip distribution and stress field. Together with stress inversion from aftershock focal mechanisms, we show that the principal stress direction rotation in the region with the most normal‐faulting aftershocks is the staggering 29°. The induced heterogenous stress may explain the shift of the dominant focal mechanism toward normal faulting. We suggest that the extensional horsetail splay faults, likely formed through geologic time scale related to the releasing bend on the EAF, are the hosts of most of the normal faulting aftershocks.

Abstract Background Gram staining is a classic but standard and essential procedure for the prompt selection of appropriate antibiotics in an emergency setting. Even in the era of sophisticated medicine with technically developed machinery, it is not uncommon that a classic procedure such as Gram staining is the most efficient for assisting physicians in making therapeutic decisions in a timely fashion. Case presentation A 65-year-old Asian man with alcoholic cirrhosis complicated by esophageal varices was brought to the emergency division of Saga Medical School Hospital in early August, complaining of severe pain, redness, swelling, and purpura of the lower extremities. On physical examination he appeared in a critically ill condition suggestive of deep-seated soft tissue infection, raising a pre-test probability of streptococci, staphylococci, Vibrio sp., or Aeromonas sp. as a causative pathogen. A characteristic of his residency in an estuarine area is that raw seafood ingestion, as documented in this patient prior to the current admission, predisposes those who have a chronic liver disease to a life-threatening Vibrio vulnificus infection. Given the pathognomonic clinical features suggestive of necrotizing fasciitis, our immediate attempt was to narrow down the differential list of candidate pathogens by obtaining clinical specimens for microbiological investigation, thus inquiring about the post-test probability of the causative pathogen. The Gram stain of the small amount of discharge from the test incision of the affected lesion detected Gram-negative rods morphologically compatible with V. vulnificus. After two sets of blood culture, intravenous meropenem and minocycline were immediately administered before the patient underwent emergency surgical debridement. The next day, both blood culture and wound culture retrieved Gram-negative rods, which were subsequently identified as V. vulnificus by mass spectrometry, matrix-assisted laser desorption/ionization. The antibiotics were switched to intravenous ceftriaxone and minocycline. Conclusion The pre-test probability of V. vulnificus infection was further validated by on-site Gram staining in the emergency division. This case report highlights the significance of a classic procedure.

Phreatic volcanic eruptions can be unexpected and devastating. Here the authors, using seismic-based methodologies, find that pressurized fluids accumulated 5 months before the deadly phreatic eruption at Mt Ontake; a period previously considered as completely quiescent.

Abstract The slip history of short-term slow slip event (SSE) is typically inferred from daily Global Positioning System (GPS) data, which, however, cannot image the sub-daily processes, leaving the underlying mechanisms of SSEs elusive. To address the temporal resolution issue, we attempted to employ the kinematic subdaily GPS analysis, which has never been applied to SSE studies because its signal-to-noise ratio has been believed too low. By carefully post-processing sub-daily positions to remove non-tectonic position fluctuation, our 30-min kinematic data clearly exhibits the transient motion of a few mm during one Cascadia SSE. A spatiotemporal slip image by inverting the 30-min data exhibits a multi-stage evolution; it consists of an isotropic growth of SSE followed by an along-strike migration and termination within the rheologically controlled down-dip width. This transition at the slip growth mode is similar to the rupture growth of regular earthquakes, implying the presence of common mechanical factors behind the two distinct slip phenomena. The comparison with a slip inversion of the daily GPS demonstrates the current performance and limitation of the subdaily data in the SSE detection and imaging. Better understanding of the non-tectonic noise in the kinematic GPS analysis will further improve the temporal resolution of SSE.

Abstract The noise level of kinematic Global Positioning System (GPS) coordinates is much higher than static daily coordinates. Therefore, it needs to be improved to capture details of small sub-daily tectonic deformation. Multipath is one of the dominant error sources of kinematic GPS, which the sidereal filter can mitigate. With increasing interest in applying kinematic GPS to early postseismic deformation studies, we investigate the characteristics of multipath errors and the performance of the position-domain sidereal filter using 30-s kinematic coordinates with a length of nearly 5 days. Experiments using three very short baselines mostly free from atmospheric disturbances show that multipath signature in position-domain has better repeatability at longer periods, and sidereal filtering without low-pass filtering yields a lift of power spectral density (PSD) at periods shorter than 200 s. These results recommend an empirical practice of low-pass filtering to a sidereal filter. However, a moderate cut-off period maximizes the performance of the sidereal filter because of the smaller multipath signature at longer periods. The amplitude of post-sidereal-filtered fluctuation is less than 6 mm in standard deviation, which demonstrates the nearly lowest noise level of kinematic GPS used for postseismic and other tectonic deformation studies. Our sidereal filter is proven to mitigate several peaks of power spectral density at periods up to 100,000 s, but the period dependency of PSD is not fully alleviated by sidereal filtering, which needs future investigation. Graphical Abstract

Abstract We present detailed maps of local-scale 3D deformation preceding the 2018 phreatic eruption at Iwo-yama volcano (south of Kyushu Island, Japan), using a combination of airborne and spaceborne Interferometric Synthetic Aperture Radar (InSAR) data. The 3D and 2.5D deformation maps obtained at different periods allow us to successfully track their spatiotemporal evolution and to infer the transition of subsurface conditions responsible for the precursory deformation observed from 2014 to 2018. From 2014 to 2016, ground inflation depicted an axisymmetric pattern with the maximum displacement at the center of the deformed area. However, from 2016 to 2018, an inflation peak moved to the southern edge of the area deformed during 2014–2016 and became more localized, which was close to the newly generated vents in the 2018 eruption. Modeling of the inflations suggests that pressurization within a crack at a depth of 150 m beneath the Iwo-yama geothermal area caused the 2014–2016 deformation and had continued until the 2018 eruption. Modeling results highlight the persistence of the local ground inflation pattern just above the southern edge of the crack, which suggests the presence of a shallower inflation source contributing to the local inflation. Consequently, we interpret the sequence of these deformations as follows: from 2014, deeper-rooted fluid started to inject into a fluid-saturated crack at 150-m depth, which caused the 2014–2016 deformation. Then, after 2016, the crack inflation continued because of the continuous fluid injection and formed another pressurized part directly above the southern tip of the crack. Additionally, the results of the time-series analysis of the satellite InSAR data revealed that the local inflation started around April 2017 for which thermal activity including a mud emission became pronounced around the location of the local inflation. As a result of an episodic increase in supply rate of magmatic fluids from a deep magma reservoir from early 2018, a phreatic eruption finally occurred in the vicinity of the most deformed point, providing a clue for predicting future eruption sites, as was also observed in the Hakone 2015 eruption.

Abstract Coeruptive deformation helps to interpret physical processes associated with volcanic eruptions. Because phreatic eruptions cause small, localized coeruptive deformation, we sometimes fail to identify plausible deformation signals. Satellite synthetic aperture radar (SAR) data allow us to identify extensive deformation fields with high spatial resolutions. Herein, we report coeruptive crustal deformation associated with the 2018 Kusatsu-Shirane phreatic eruption detected by time series analyses of L-band satellite SAR (ALOS-2/PALSAR-2) data. Cumulative deformation maps derived from SAR time series analyses show that subsidence and eastward displacement dominate the southwestern side of an eruptive crater with a spatial extent of approximately 2 km in diameter. Although we were unable to identify any significant deformation signals before the 2018 eruption, posteruptive deformation on the southwestern side of the crater has been ongoing until the end of 2019. This prolonged deformation implies the progression of posteruptive physical processes within a confined hydrothermal system, such as volcanic fluid discharge, similar to the processes observed during the 2014 Ontake eruption. Although accumulated snow and dense vegetation hinder the detection of deformation signals on Kusatsu-Shirane volcano using conventional InSAR data, L-band SAR with various temporal baselines allowed us to successfully extract both coeruptive and posteruptive deformation signals. The extracted cumulative deformation is well explained by a combination of normal faulting with a left-lateral slip component along a southwest-dipping fault plane and an isotropic deflation. Based on the geological background in which the shallow hydrothermal system develops across Kusatsu-Shirane volcano, the inferred dislocation plane can be considered as a degassing pathway from the shallow hydrothermal system to the surface due to the phreatic eruption. We reconfirmed that SAR data are a robust tool for detecting coeruptive and posteruptive deformations, which are helpful for understanding shallow physical processes associated with phreatic eruptions at active volcanoes.

Mt. Bromo is geographically located in eastern of Java Island at 112°57'30'' longitude and 7°56' latitude, with a large area of caldera ~10 Km2. The land over the volcano is a perfect area for farming, one of the important factor affects the level of soil fertility is the most mineral rich soils. Volcanic activities at Mt. Bromo has been recorded in 1775 which characterized by small eruptions with cycles ranging from one to five years. Regarding this evidence, we tried to investigate the surface changes over the Mt. Bromo by using Time-Series InSAR with TimeFun algorithm. TimeFun is an extension of SBAS to allow incorporating various functions such as seasonal oscillations, polynomials, and step functions as generally it estimates DEM errors as well and allows missing observation. The maximum allowed baseline value is defined and used to constrain the interferogram pair by selecting manual after differential InSAR processing in single face working. The proposed analysis is based on 27 SAR data sets acquired by the ALOS/PALSAR sensors during the 2007–2017 time interval. The result shows us deformation occurred up to ~10 cm at summit of Mt. Bromo during the eruption period. Time-series monitoring of surface deformation to infer volume changes, geometries and locations of sources of deformation involved in the future eruption

Abstract An unusual devastating tsunami occurred on September 28, 2018 after a strike‐slip faulting earthquake in Sulawesi, Indonesia. The induced tsunami struck Palu city with ∼4‐m flow depth. We performed two analyses to investigate the source of the tsunami. We first conducted the teleseismic source inversion and obtained the overall slip distribution of the strike‐slip fault. Our tsunami simulation from the coseismic deformation of the seismically estimated strike‐slip faulting produced a tsunami comparable to the leading part of the observation at Pantoloan. In order to reconstruct the detailed slip distribution on the fault plane, we then jointly utilized the tsunami waveform and Synthetic Aperture Radar (SAR) data. Because of the lack of SAR data in the bay, the tsunami data is necessary to constrain the offshore slip distribution, which directly induces the tsunami. The inverted source model shows a strike‐slip fault which consists of three segments extending from the epicenter to the south of 1.4°S with two bends and two asperities around Palu city. The joint inversion model accurately reconstructs the observed surface displacements and the leading part of the tsunami waveform. Our result exhibits the significant contribution of the strike‐slip faulting to the tsunami, but it also suggests additional tsunami sources, such as landslides, for the high inundations near Palu bay. The result also indicates that regional devastating tsunamis can be generated by an onshore strike‐slip fault with localized large dip slip.

In this study, the authors monitor a hydrothermal fluid surge through seismic anisotropy changes at the Hakone volcanic field, Japan. The authors find the anisotropy changes to be set off by the seismic waves of the 2011 Tohoku-Oki earthquake, that reactivated the hydrothermal system.

Abstract Asama volcano is one of the most active volcanoes in Japan. Spatially dense surface deformation at Asama volcano has rarely been documented because of its high topography and snow cover around the summit. This study presents the first interferometric synthetic aperture radar (InSAR) observation of ground deformation at Asama volcano with 120 Sentinel-1 SAR images from both ascending and descending tracks and 20 descending ALOS-2 images acquired between 2014 and 2018. We exploited both persistent and distributed scatterers to overcome decorrelation of SAR signals and applied a three-dimensional unwrapping method to retrieve the displacement time series efficiently. Our observations reveal an asymmetric deformation around the volcano with two main deformation regions on the northeast and southeast flanks, respectively. The northeast flank (NEF) exhibits line-of-sight (LOS) extensions in all the three SAR datasets with maximum velocities of − 14, − 10, and − 12 mm/year for the descending ALOS-2, ascending, and descending Sentinel-1 measurements, respectively. The southeast flank (SEF) shows LOS extensions in the ascending observations and LOS shortening in the descending observations with velocities between − 12 and 9 mm/year. Decomposition of the LOS displacements reveals nearly pure subsidence at the NEF, while the SEF exhibits a substantial eastward component as well as subsidence. Comparisons of the vertical subsidence at two continuous GNSS stations near the summit crater with our InSAR observations indicate small discrepancies smaller than 4 mm/year. We interpreted that the subsidence at the NEF of Asama is primarily due to the hydrothermal activity, while the deformation at SEF is plausibly due to flank instability. We highlight that efforts should be taken to monitor the slope instability at Asama volcano in the future.

We observe the surface deformation of the Mt. Bromo which located at eastern Java Indonesia area that includes neighborhood volcanic system on TNBTS (Taman Nasional Bukit Tengger Semeru). Recently, remote sensing has played as an important role to observe volcano behaviour. We apply the SAR Interferometry (InSAR) algorithm referred to as Small Baseline Subset (SBAS) approach that allows us to generate mean deformation velocity maps and displacement time series for the studied area. The common SBAS technique, the set of interferometric phase observations writes as a linear combination of individual SAR scene phase values for each pixel independently. Particularly, the proposed analysis is based on 22 SAR data acquired by the ALOS/PALSAR sensors during the 2007–2011 time interval. A fewer studies have been able to show capability of InSAR analysis for investigating cycle of volcano especially of Mt. Bromo which characterized eruption stratovolcano in ranging one to five years. The results expected in this work represent an advancement of previous InSAR studies of the area that are mostly focused on the deformation affecting the caldera. According to the result, we expected this study could implement on risk management or infrastructure management.

Summary: Background: Central line-associated bloodstream infection (CLABSI) is a serious complication of central venous catheter (CVC) placement in patients with haematological diseases associated with neutropenia and immunosuppression. However, whether the venues where CVC are inserted influence CLABSI development remains unclear. Methods: We investigated whether CVC insertion at venues with different standards of cleanliness altered the occurrence of CLABSI. We evaluated data from 279 patients (545 CVC insertions) with haematological diseases including age, sex, underlying disease, reason for insertion, insertion site, number of lumens, venue, dates of insertion and removal, complete blood counts, percentage of neutrophils and serum albumin concentrations at the time of CVC insertion. Findings: Overall, 55 CLABSI events occurred during a period of 23,434 catheter days (2.35 per 1,000 catheter days). In total, 153 and 190 patients underwent 226 and 305 CVC insertions, respectively in a ward and in an operating room, respectively. Univariate analysis identified the operating room (P = 0.017), allogeneic haematopoietic stem cell transplantation (P < 0.001), triple lumen catheter (P = 0.002), haemoglobin (P = 0.019), white blood cell count (P = 0.012) and percentage of neutrophils (P = 0.012) as significant factors for the development of CLABSI. However, multivariate analysis adjusted for age, reason for insertion, insertion site, number of lumens, haemoglobin, percentage of neutrophils and platelet counts found no significant differences between the venue where CVC were inserted and CLABSI development (P = 0.158). Conclusion: The venue of CVC insertion is unlikely to influence CLABSI development in patients with haematological diseases. Keywords: Central venous catheter, Central line-associated bloodstream infection, Haematological malignancy, Leukaemia, Ward, Operating room

Intravenous administration of 2 g carnitine in every hemodialysis (3 times/week), for 8–10 months, reduced doses of darbepoetin alfa required to maintain adequate hemoglobin levels (10–11 g/dL) into 10% of the initial doses. There was also a significant increase in plasma transferrin saturation, increase in left ventricular ejection fraction, and decrease in plasma brain natriuretic peptides.

Volcanic islands in remote settings are challenging to study with ground-based instrumentation; nevertheless it is important to define “normal” background activity at these volcanoes because they pose threats to air and sea traffic. A combination of remote sensing methods is critical to adequately characterize volcanic activity, and in this study we present space-based observations of both thermal anomalies and surface deformation at Pagan Island in the Mariana Island Arc. Mt. Pagan produced a large eruption (>0.1 km3) in 1981, and recent smaller eruptions (>0.001 km3) in 2011 and 2012 that triggered volcanic ash advisories. In this study we examine available Interferometric Synthetic Aperture Radar (InSAR) from Envisat and ALOS between October 2004 and June 2010 for precursory deformation leading up to the most recent eruptions. Although we do not observe evidence for shallow magma reservoir inflation, we do observe a zone of subsidence of up to -3 cm/yr located on the northern flank likely caused by continuing scoria compaction of 1981 eruptive deposits. CosmoSkyMed InSAR measurements spanning the October 2012 eruption also shows deposit subsidence, but no detectable co-eruptive deflation. We also present remotely-sensed thermal time series from the MODIS and ASTER instruments spanning over a decade. There are two distinct locations of anomalous surface temperatures on the island, which correlate with previously documented, fumarolically active vents at South Pagan and Mt. Pagan. Ultimately, we did not find thermal or deformation precursors for recent eruptive activity, plausibly because the volcano had an open conduit and persistent degassing during this time period. We compare and contrast the efficacy of various sensor types currently available to characterize transient dynamics at small and remote volcanic islands such as Pagan.

Quantifying the eruption potential of a restless volcano requires the ability to model parameters such as overpressure and calculate the host rock stress state as the system evolves. A critical challenge is developing a model-data fusion framework to take advantage of observational data and provide updates of the volcanic system through time. The Ensemble Kalman Filter (EnKF) uses a Monte Carlo approach to assimilate volcanic monitoring data and update models of volcanic unrest, providing time-varying estimates of overpressure and stress. Although the EnKF has been proven effective to forecast volcanic deformation using synthetic InSAR and GPS data, until now, it has not been applied to assimilate data from an active volcanic system. In this investigation, the EnKF is used to provide a “hindcast” of the 2009 explosive eruption of Kerinci volcano, Indonesia. A two-sources analytical model is used to simulate the surface deformation of Kerinci volcano observed by InSAR time-series data and to predict the system evolution. A deep, deflating dike-like source reproduces the subsiding signal on the flanks of the volcano, and a shallow spherical McTigue source reproduces the central uplift. EnKF predicted parameters are used in finite element models to calculate the host-rock stress state prior to the 2009 eruption. Mohr-Coulomb failure models reveal that the host rock around the shallow magma reservoir is trending toward tensile failure prior to 2009, which may be the catalyst for the 2009 eruption. Our results illustrate that the EnKF shows significant promise for future applications to forecasting the eruption potential of restless volcanoes and hind-cast the triggering mechanisms of observed eruptions.

The Sichuan basin (SCB) is situated at the southeastern edge of the Tibetan Plateau where widespread seismicity has occurred. In the past decades, seismic events occurred in and around SCB have been responsible for more than 100 thousand casualties. To quantify the present-day seismic hazard of this region, especially the densely populated Chengdu-Chongqing economic zone (CCEZ), we develop a probabilistic earthquake forecast model using strain rates derived from 187 Global Navigation Satellite System (GNSS) horizontal velocities, of which 102 velocity vectors are first released. The second invariant of the strain rate tensor suggests that the Shimian County and its surroundings are exposed to the highest seismic hazard in and around SCB. The second most dangerous area is located between 103-105°E. The Chongqing area is the least dangerous. The principal strain rate axes interior of the Sichuan basin suggest that this region is experiencing broad-scale extension, which according to our knowledge, is first revealed by our dense GNSS network. The comparison between the cumulative histograms of the second invariant of geodetic strain rate and earthquake count indicates that the geodetic strain rates in this region can serve as a reliable predictor of M≥6 earthquake locations. Thus, we proceed to calculate the total seismic moment anticipated for the entire area within the next 30 years. [ABSTRACT FROM AUTHOR]

Most undergraduate and graduate students at medical schools have a high level of reading and writing skills in English; however, they have little confidence in speaking freely with patients and colleagues. Even though Japanese students are required to study English as a second language for longer than students in other countries, their conversational ability is often limited. Therefore, it is important to learn real-world English to be able to better communicate with patients, fellow health care workers, and colleagues. In their Academic Writing courses at Saga University, graduate students learn how to prepare for conference presentations and practice their delivery methods, often by memorization through repeated rehearsals. In general, they present their studies thoroughly; however, when native English speakers ask questions during the Q&A sessions, they tend to draw blank as this takes them off script. Learning to engage with questions without a script is a valuable skill for graduate students; furthermore, they will inevitably be interacting with a diverse audience and can build the confidence to communicate effectively. The course evaluation revealed that the graduate students enjoyed the exercises and experience and were inspired to improve their conversational skills. It is essential not only to teach medical English in reading and writing, but also to provide opportunities to explain research topics as well as symptoms and prognoses of patients in plain English. Given that more medical students are interested in practicing medicine abroad, and that increasing numbers of foreign patients are coming to Japanese hospitals for treatment, even in rural areas, the necessity of obtaining real-world English skills is more essential now than ever. [ABSTRACT FROM AUTHOR]