Comprehensive Management of Vasculitis and Suspected Polyarteritis Nodosa in an Older Patient.

Polyarteritis nodosa (PAN) is a rare autoimmune disease that affects medium-sized arteries and causes inflammation and damage to the blood vessel walls. Testicular pain is an uncommon symptom of PAN but can occur in rare cases. This specific symptom may be useful in diagnosing older patients with limited tissue access because of their vulnerability and high risk for biopsy complications. We report the case of a 78-year-old male patient with progressive fatigue and walking difficulty. After ruling out various forms of vasculitis and malignancy, we diagnosed the patient with PAN and intensively treated him with rituximab, which successfully cured his symptoms. This case report highlights the importance of intensively ruling out possible diagnoses mimicking vasculitis and treating vasculitis with a tentative diagnosis of PAN in older patients in rural hospitals. The progressive clinical course of vasculitis may devastate older patients' activities of daily living (ADLs). PAN may particularly affect older patients with possible hepatitis B infections. Thus, shared decision-making and prompt intensive treatment should be considered.

Timing of Treatment for Cytomegalovirus Infection in an Immunocompetent Middle-Aged Woman With Fulminant Ulcerative Colitis: A Case Report.

Viral infections, such as cytomegalovirus (CMV) infection, may affect the clinical course of ulcerative colitis (UC). CMV can cause chronic inflammation of the intestinal mucosa. In inflammatory bowel disease, chronic inflammation caused by CMV can deter the regeneration of the mucosa of the colon. However, the relationship between CMV and inflammatory bowel disease still needs to be clarified, especially in immunocompetent patients, such as younger patients not treated with immunosuppressants. Herein, we describe our experience with a middle-aged immunocompetent female patient diagnosed with fulminant UC positive for myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA). Her initial response to high-dose prednisolone was favorable; however, remission was not achieved. Immunohistochemical staining revealed the presence of CMV. Subsequently, the patient was successfully treated with prednisolone, adalimumab, and azathioprine, along with the anti-CMV treatment comprising valganciclovir. This case shows that the presence of CMV in the mucosa and blood may make patients with UC refractory to immunosuppression; furthermore, the positivity of MPO-ANCA in patients with UC can necessitate the administration of high-dose immunosuppressants to taper the dose of prednisolone.

Heyde Syndrome Complicated by Essential Thrombocythemia: A Case Report.

Heyde syndrome is a multisystem disorder characterized by the triad of aortic stenosis (AS), gastrointestinal bleeding, and acquired von Willebrand syndrome. Age-related degeneration is the most common cause of aortic stenosis and is frequently encountered in today's aging society. Approximately 20% of patients with severe aortic stenosis have Heyde syndrome. We encountered an older patient with primary thrombocytosis who was brought to a rural community hospital with bloody stools and was diagnosed with bleeding from an intestinal arteriovenous malformation. A final diagnosis of Heyde syndrome was made based on the presence of severe aortic stenosis and the presence of schistocytes in peripheral blood smears. Valvular diseases can complicate chronic hematological diseases. When the rapid progression of anemia and segmented red blood cells in the peripheral blood are observed in patients with severe aortic stenosis, Heyde syndrome should be considered based on peripheral blood smears and clinical course.

Appearance of Ankylosing Spondylitis in a Middle-Aged Female Patient With a Long History of Rheumatoid Arthritis.

Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial bones, primarily affecting the spine. AS is classified as spondyloarthritis because it affects the spine and other joints. AS has several presentations and, in some cases, can be insidious, making it difficult to diagnose. We encountered a patient on long-term follow-up for rheumatoid arthritis with an appearance of AS. This case suggests that patients with long-term rheumatoid arthritis can develop AS during follow-up and that the seropositivity of rheumatoid factors and anti-cyclic citrullinated peptide antibodies cannot rule out AS. Therefore, the possibility of AS should be considered, even in patients diagnosed with rheumatoid arthritis.

Metabolism-Mediated Thrombotic Microangiopathy in an Older Patient Without Malnutrition.

Vitamin B12 deficiency can cause thrombotic microangiopathy (TMA)-like symptoms such as purpura caused by platelet reduction, general fatigue caused by anemia, and renal and hepatic abnormalities caused by malnutrition. TMA-like symptoms are known as metabolism-mediated TMA (MM-TMA). In MM-TMA, blood cell production is altered, and both pancytopenia and schistocytes appear. The initial presentation of MM-TMA makes it challenging to distinguish between primary and secondary TMA when patients do not present risk factors for malnutrition. We encountered an older female patient with a chief complaint of unconsciousness and loss of appetite for two days. Laboratory tests revealed pancytopenia with schistocytes. Moreover, the laboratory data revealed low serum levels of vitamin B12, indicating MM-TMA. The patient was successfully treated with intravenous vitamin B12 supplementation and discharged home. The patient had atrophic gastritis, which could have impeded the absorption of vitamin B12 from food. Among older patients without prolonged appetite loss, TMA-like symptoms should be investigated as MM-TMA induced by vitamin B12 deficiency, and prompt initiation of appropriate treatment is essential to differentiate between MM-TMA and true TMA.

Associations between Perception of Help-Seeking Behaviors and Quality of Life among Older People in Rural Communities: A Cross-Sectional Study.

Older people's help-seeking behaviors (HSBs) may be limited because of various factors and are essential in improving healthcare in aging societies. This cross-sectional study investigated the association between perception of HSBs, concrete HSBs, quality of life (QOL), and other variables among people over 65 in rural Japan using standardized questionnaires. Participants were divided into high or low health status index score groups based on a median split. Logistic regression was used to assess the association between perception of HSBs and high QOL while controlling for age, sex, living conditions, annual health checks, having chronic diseases, regular clinic visits, smoking, habitual alcohol consumption, education, living conditions, social support, social capital, socioeconomic status (SES), and health literacy. Participants in the high QOL group were younger (p < 0.001), and had fewer chronic diseases and regular clinic visits than those in the low QOL group (p < 0.001). The multivariate logistic regression model revealed that age, chronic diseases, tobacco usage, family consultation, and consulting primary care physicians negatively predicted QOL. High SES, social capital and support, and HSB intention positively predicted QOL. Self-efficacy and intention regarding HSBs should be investigated to improve health among older rural people.

Hypoglossal Nerve Palsy Following COVID-19 Vaccination in a Young Adult Complicated by Various Medicines.

Mononeuritis multiplex is a rare form of cerebral nerve palsy caused by various factors. Coronavirus disease 2019 (COVID-19) vaccination could be an etiology of mononeuritis multiplex, which can affect various nerves. Post-COVID-19 and vaccination-related neurological impairments involve cranial nerves such as the facial, trigeminal, and vagal nerves. We report our experience with a 34-year-old man who developed hypoglossal nerve palsy following COVID-19 vaccination, complicated by progressive mononeuritis multiplex. Hypoglossal nerve palsy may occur following COVID-19 vaccination. The symptoms vary and may progress without treatment. Physicians should consider the possibility of mononeuritis multiplex after COVID-19 vaccination and provide prompt treatment for acute symptom progression.

Secondary Failure of Tocilizumab in Treating Elderly-Onset Rheumatoid Arthritis With Systemic Symptoms Complicated by Diverticulum Perforation.

The treatment of rheumatoid arthritis (RA) has advanced from the use of steroids to disease-modifying anti-rheumatic drugs (DMARDs) and biologics such as tumor necrosis factor (TNF) and interleukin-6 (IL-6) inhibitors. Historically, steroids have been the mainstream in the clinical treatment of RA; however, the development of DMARDs has changed the RA treatment structure. In addition, biologics can alleviate RA symptoms. This case report describes the secondary failure of tocilizumab in treating RA with fatigue symptoms. Treatment with tocilizumab decreases C-reactive protein (CRP) levels, which may make detecting RA exacerbation difficult; therefore, obtaining the patient's precise history and thorough physical examinations are necessary. This case demonstrates the complexity of treating elderly-onset RA and reports practical methods for effective treatment.

Seronegative Ocular Myasthenia Gravis in an Older Woman With Transient Dizziness and Diplopia.

Myasthenia gravis (MG) is a neuromuscular junction disease caused by an autoimmune response against cholinergic receptors. The challenge in diagnosing MG in older patients is the variety of symptoms and clinical manifestations. Clinical reasoning, precise history, and physical examination leading to a logical diagnosis should be performed to diagnose seronegative MG. We report a case of seronegative MG with the chief complaint of dizziness in a 91-year-old female. Despite the complicated clinical course, continuous clinical reasoning and testing can lead to appropriate diagnosis and treatment. As the dizziness symptoms in this older patient could not be explained by chronic or peripheral symptoms alone, ocular MG was considered as a possible diagnosis based on her history and physical examination findings. Appropriate diagnosis of seronegative ocular MG reactivated older patients with a good quality of life. In community medicine, where the behavior of elderly patients varies, it is important to improve the accuracy of diagnosis and treatment through appropriate history and physical examination, which will lead to longer home life in older patients.

Autoimmune Vasculitis Causing Acute Bilateral Lower Limb Paralysis.

Autoimmune vasculitis is an autoimmune disease that causes various systemic symptoms, such as fever, fatigue, joint pain, and night sweats. Its clinical course depends on the severity of the inflammation, which can cause acute clinical progression of symptoms. Moreover, when the inflammation of the arteries occurs in the deeper parts of the body, a biopsy may be difficult to perform. Here, we report a case of autoimmune vasculitis in an elderly man who visited our hospital with a chief complaint of muscle pain and fever triggered by a rapid paralysis of both lower limbs. Autoimmune vasculitis can cause a variety of systemic symptoms depending on the size of involved arteries, and its clinical course depends on the severity of the inflammation. Prompt diagnosis and simultaneous treatment of symptoms, excluding other likely diseases, prevent the development of severe and long-term complications of autoimmune vasculitis.

Giant Cell Arteritis Mimicking Polymyalgia Rheumatica: A Challenging Diagnosis.

Giant cell arteritis (GCA) is an autoimmune disease that causes inflammation of the middle and large arteries. Rural areas have many older patients with various symptoms, so large-vessel-type GCA should be managed effectively. Older patients tend to show vague symptoms that cannot be adequately diagnosed and observed. Here, we have encountered a case of a 91-year-old woman with a chief complaint of fatigue diagnosed with large-vessel type GCA in collaboration with a rural clinic. Effective collaboration between physicians in rural hospitals and clinics is necessary for diagnosing and treating large-vessel GCA. In rural areas, without adequate healthcare professionals, physicians should share their abilities and collaborate smoothly to mitigate delays in consultation and treatment. To effectively treat large vessel-type GCA, rural general physicians should be familiar with the clinical course of the disease and treatment for rural comprehensive care.

Rural Easy Japanese as a Method of Mitigating Language Barriers Among Foreigners Seeking Medical Care in Rural Japan.

Mitigating difficulties in communication is vital in multicultural societies. Particularly, foreigners face greater communication difficulties because of language barriers, posing a challenge to both themselves and indigenous people. In Japan, the increase in the number of foreigners has driven the use of Easy Japanese, a free online program of Japanese language lessons. Easy Japanese can facilitate communication between medical professionals and foreigners. Easy Japanese is mainly characterized by short sentences, an upfront conclusion, and avoiding polite Japanese words when collaborating with translators. This communication method should prevail not only in urban areas but also in rural areas, and can help individuals in rural contexts prepare for an increase in the number of foreigners.

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.

Hemodialysis-Related Pericarditis With Cardiac Tamponade.

Pericarditis can cause chest symptoms in dialysis patients. Moreover, it tends to present with various symptoms other than chest pain in patients with end-stage renal disease (ESRD) than in non-ESRD patients. Here, we present the case of an 86-year-old man on maintenance dialysis who was admitted to the hospital with chest discomfort and dyspnea, which led to cardiac tamponade due to unexplained pericardial effusion. The patient underwent pericardial drainage with an epigastric approach. Based on his medical history and pericardial fluid examination, his condition was diagnosed as dialysis-related pericarditis. Non-steroidal anti-inflammatory drugs and prednisolone administration improved the patient's condition. There are various causes of pericarditis in patients undergoing hemodialysis. It is crucial to examine the patient's clinical presentation and pericardial fluid volume to clarify the cause of the disease.

Improvement in Quality of Life through Self-Management of Mild Symptoms during the COVID-19 Pandemic: A Prospective Cohort Study.

The COVID-19 pandemic has inhibited people's help-seeking behaviors (HSBs). In particular, older people in rural communities experienced limited access to medical care, which negatively affected their quality of life (QOL). Within HSB, self-management of mild symptoms may mitigate the difficulties experienced by older people in rural communities. However, few studies have examined the relationship between self-management and QOL. Therefore, we conducted a prospective cohort study to clarify this relationship. Our participants were over 65 years of age and lived in rural communities. QOL was measured with the EuroQol 5-Dimension 5-Level (EQ-5D-5L). Demographic data and QOL were collected from participants via questionnaires in 2021 and 2022. The exposure group showed a significantly greater change in EQ-5D-5L health status index scores than the control group (p = 0.002). In addition, the exposure group scored significantly lower than the control group on the EQ-5D-5L dimension "usual activities" in 2021 and on all dimensions in 2022. Thus, self-management of mild symptoms may improve QOL among older people in rural communities during the COVID-19 pandemic. Educational interventions for this population regarding self-management could improve QOL for entire communities.

A Solution for Loneliness in Rural Populations: The Effects of Osekkai Conferences during the COVID-19 Pandemic.

Social prescribing is an essential solution to the lack of social connection and interaction and provides a key approach to problems faced by communities during the COVID-19 pandemic. One social prescription used in Japan is the Osekkai conference, which has the potential to increase social participation in rural communities. The revitalization of Osekkai can improve social interactions among people involved in the conference, thereby reducing loneliness. This interventional study was conducted with people who participated in the Osekkai conference. The primary outcomes of the degree of loneliness were compared between 2021 and 2022 using the Japanese version of the three-item UCLA Loneliness Scale. The demographic data and process outcomes of participants were measured using a questionnaire. The participants' roles in the Osekkai conference increased between the two periods. Loneliness scores tended to decrease during the study period (4.25 to 4.05, p = 0.099). In the questionnaire on loneliness, the scores for item 2 decreased significantly during the study period (1.36 to 1.25, p = 0.038). In conclusion, this study shows that the continual provision of Osekkai conferences as a social prescription may reduce the degree of loneliness among participants with improved social participation in rural communities. Future studies should investigate comparative interventions to show the effectiveness of social prescription on loneliness in communities.

A Rare Case of Herpes Esophagitis in an Immunocompetent Elderly Patient.

Herpes esophagitis is common among immunocompromised hosts but is relatively rare among immunocompetent patients. Its symptoms are vague because many different symptoms can be induced by esophageal lesions. Here, we report a case of herpes esophagitis in an elderly immunocompetent patient. A 91-year-old woman visited our community hospital with a complaint of appetite loss for several days. Although she did not have any symptoms of epigastric, oral, or retrosternal pain, multiple ulcers were detected in her esophagus. Biopsy of the edge of the ulcer showed giant cells, indicating a herpes virus infection. She was diagnosed with herpes esophagitis and treated with acyclovir for one week. Her symptoms completely resolved after treatment, and she was discharged. Herpes esophagitis can manifest as vague symptoms in immunocompetent elderly patients. Therefore, herpes esophagitis must be considered in the differential diagnosis of elderly patients presenting with vague symptoms.

Exploring the Competencies of Japanese Expert Nurse Practitioners: A Thematic Analysis.

Nurse practitioners (NPs) provide medical care equivalent to that of physicians and facilitate access to healthcare. Although Japan's first NP graduated in 2010, how Japanese expert NPs work effectively in clinical contexts is yet to be investigated. We aimed to identify the competencies that make expert NPs in Japan effective. Twelve Japanese expert NPs were purposely selected. The average age of the participants was 44.8 years, average NP experience was 7.5 years, and eight participants were women. Semi-structured interviews were conducted online from March to May 2021. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. Thematic analysis revealed five themes: working in physicians' contexts, interprofessional collaboration, involvement in nurses' work, contribution to healthcare, and personal qualities for effective working. Japanese expert NPs can function effectively in clinical settings by flexibly and humbly collaborating with other medical professionals who have autonomous positions. They can improve the quality of healthcare by proposing practical solutions to problems faced by patients and medical organizations. These explored competencies can be applied to other aging and more complex societal contexts, and in updating the required competencies of Japanese NPs.