Inquiry Into Physicians' Scope of Practice in Japanese Rural Hospitals During the COVID-19 Pandemic: A Serial Cross-Sectional Study.

Introduction Physicians' scope of practice (SoP) depends on clinical settings and is related to how motivated they feel. The clarification and differences in the SoP in each clinical setting are necessary for physicians' careers. This study aimed to investigate how coronavirus disease 2019 (COVID-19) affected physicians' SoP. Methods This serial cross-sectional study compares the differences in physicians' SoP among Japanese rural community hospitals between 2018 and 2020. The participants were admitted patients in the internal medicine wards of the two community hospitals in urban and rural districts in the rural prefecture (Shimane) of Japan from January 1, 2018, to December 31, 2020. We calculated the number of health problems among the highest 50% of all health problems for each physician (SoP-50%) and used it as an indicator of the comprehensiveness of clinical practice. Results The study found that SoP-50% was significantly higher in rural districts in 2018 (p = 0.0209). This trend remained unchanged even during the COVID-19 in 2020 (p = 0.0441). While there was a significant regional difference in the SoP, pre and post-COVID-19 analysis of the SoP in each region did not show any significant change. Conclusion This is the first study to indicate that greater comprehensiveness of clinical practice is required in the districts of rural Japan. The findings can be helpful for physicians' medical education and career choices.

Tocilizumab and Baricitinib for Recovery From Acute Exacerbation of Combined Pulmonary Fibrosis and Emphysema Secondary to COVID-19 Infection: A Case Report.

Pneumonia secondary to coronavirus disease 2019 (COVID-19) is exacerbated by a disproportionate increase in the systemic inflammatory response and cytokine storm due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Herein, we report the successful treatment of severe COVID-19 pneumonia using a combination of tocilizumab and baricitinib in a patient with combined pulmonary fibrosis and emphysema (CPFE). A 67-year-old male with type 2 diabetes mellitus and CPFE presented with fever and dyspnea and was diagnosed with COVID-19. Upon admission, his respiratory failure was managed using high-flow nasal cannula (HFNC) therapy; however, despite treatment with remdesivir and systemic steroids, his respiratory failure continued to worsen. Therefore, baricitinib was administered from the ninth day of hospitalization for 14 days. Furthermore, his blood interleukin-6 (IL-6) levels showed an increase until day 13. Thus, tocilizumab was administered on the 13th day, which led to symptomatic improvement by day 18. The patient was discharged from our hospital on day 42. This case indicates that combination therapy with tocilizumab and baricitinib improves the efficacy of COVID-19 treatment in patients with comorbidities.