Anti-neutrophil Cytoplasmic Antibody-Negative Rapid Progressive Glomerulonephritis With Mild Pathological Presentation in an Older Patient: A Case Report.

This case report discusses the management of anti-neutrophil cytoplasmic antibodies (ANCA)-negative rapid progressive glomerulonephritis (RPGN) in a 68-year-old man with a complex medical history, presenting with fatigue, edema, and acute renal failure. Despite the absence of positive biomarkers for specific RPGN types, the clinical progression suggested microscopic polyangiitis, leading to intensive immunosuppressive therapy with cyclophosphamide and rituximab. The patient's condition was further complicated by the coexistence of nephritic and nephrotic syndromes, requiring nuanced management strategies, including prolonged hemodialysis. After initial treatment failure, remission was eventually achieved, allowing cessation of dialysis and significant recovery of renal function. This case highlights the challenges of diagnosing and managing ANCA-negative RPGN, particularly the importance of a tailored, dynamic approach to treatment in resource-limited settings. The recovery observed underscores the potential for renal function improvement even after prolonged periods of intensive therapy, reinforcing the need for persistence and adaptability in managing complex RPGN cases.

Chronic and Acute Drug-Induced Hypersensitivity Syndrome in a Rural Patient With Cytomegalovirus Infection: A Case Report.

A 50-year-old man presented with fever and a generalized rash, with chronic fatigue and lymphadenopathy for a year and a half. Initial tests ruled out lymphoproliferative disorders, showing reactive hyperplasia and cytomegalovirus. Symptoms worsened after ampicillin treatment, leading to suspected drug-induced hypersensitivity syndrome (DIHS). Upon admission, amoxicillin was discontinued, and prednisolone and antiviral treatment were initiated. The patient's condition improved with this therapy. A drug-induced lymphocyte stimulation test confirmed hypersensitivity to both ampicillin and allopurinol. This case illustrates the diagnostic challenge of chronic and acute DIHS because of the rare presentation. It underscores the need for high suspicion of DIHS in patients with chronic lymphadenopathy and fatigue, particularly with recent drug exposure. Effective management involves recognizing symptoms, withdrawing the offending drug, and using corticosteroids. Viral infections like cytomegalovirus can complicate DIHS diagnosis and treatment, necessitating a comprehensive approach. This case highlights the importance of considering DIHS in differential diagnoses and the complexities of managing it alongside co-infections in rural healthcare settings.

Seronegative Rheumatoid Arthritis in an Elderly Dialysis Patient With Multiple Comorbidities: A Case Report.

The diagnosis of autoimmune diseases in elderly, immunocompromised patients undergoing dialysis poses significant challenges due to the diverse etiology of symptoms such as fever and systemic pain. This case study reports on a 79-year-old man undergoing hemodialysis with a history of multiple comorbidities, including diabetes, heart failure, and pure red cell aplasia. He presented with subacute polyarthritis and fever and was ultimately diagnosed with seronegative rheumatoid arthritis. The case illustrates the complexities of differential diagnosis in this population, emphasizing the need for a systematic approach to distinguish between possible infectious and autoimmune causes. Despite the absence of rheumatoid factor and anti-citrullinated protein antibody, the patient's clinical presentation and response to steroids supported the diagnosis of seronegative rheumatoid arthritis. Treatment with prednisolone resulted in significant improvement in symptoms and quality of life, demonstrating the effectiveness of steroids in managing autoimmune conditions in elderly, high-risk patients. However, such treatment necessitates careful monitoring due to potential adverse effects. This case underlines the importance of considering autoimmune diseases in differential diagnoses and customizing treatment strategies to accommodate the unique needs of elderly, immunocompromised patients on dialysis. Insights from this case contribute to better understanding and management of complex clinical scenarios in similar patient populations.

Family Medicine Implementation to Maternal and Child Health in Rural Japan: A Narrative Review.

This research provides a critical narrative review of maternal and child health (MCH) in rural Japan, reflecting broader challenges faced by aging societies globally. The study explores the intertwined roles of professional and lay care in sustaining rural communities, emphasizing the unique position of family medicine and primary care in enhancing MCH services. The scarcity of healthcare resources, particularly the shortage of obstetricians and the weakening of traditional community support systems, underscores the challenges in these areas. Our review method involved a comprehensive search of PubMed for articles published from April 2000 to August 2024, focusing on MCH issues in rural Japan. This study highlights several critical gaps in rural MCH provision: the migration of medical professionals to urban centers, the transformation of social structures affecting traditional caregiving, and the lack of specialized MCH training among primary care physicians. We discuss potential solutions such as incentivizing obstetric care in rural areas, integrating MCH education within family medicine curricula, and revitalizing community-based support systems. By addressing these issues, the research aims to formulate actionable strategies to bolster MCH services, thus ensuring better health outcomes and sustainability of rural communities in Japan and similar settings worldwide.

Disparity of the Treatment of Unresectable Non-small Cell Lung Cancer Regarding Chemotherapy: A Systematic Review and Meta-Analysis.

This study investigates disparities in chemotherapy treatment for unresectable non-small cell lung cancer (NSCLC) between urban and rural populations. Despite advancements in NSCLC treatments enhancing survival, significant inequities persist, notably in rural areas where access to care is often limited, resulting in poorer outcomes. Through a systematic review and meta-analysis, we analyzed data from selected studies that compare chemotherapy access and usage between these populations from 2010 to 2024. Our findings indicate that rural patients are consistently less likely to receive advanced chemotherapy treatments than urban counterparts, with a pooled odds ratio of 0.91 (95% confidence interval (CI): 0.83-1.00), suggesting a marginal but noticeable disparity. This highlights a crucial gap in healthcare provision, underscoring the need for policy interventions and improved healthcare practices to ensure equitable treatment access. This research calls for further investigation into socioeconomic and cultural factors contributing to these disparities to inform targeted improvement strategies.

Linking Agricultural Activity Frequency to Loneliness in Rural Hospital Patients: A Cross-Sectional Study.

Introduction Agriculture is deeply woven into the fabric of rural life, influencing the economy, and the social and health dynamics of rural communities. While it offers physical and mental health benefits through regular physical activity and interaction with nature, the solitary nature of farming activities may also lead to social isolation. This study explores the complex relationship between the frequency of agricultural engagement and feelings of loneliness among rural inhabitants with chronic diseases, addressing a gap in the literature concerning the impact of agricultural practices on social well-being. Method A cross-sectional analysis was conducted among patients over 40 who frequented the general medicine department in Unnan City, a rural area of Japan. The study utilized the Japanese version of the University of California, Los Angeles (UCLA) Loneliness Scale to assess loneliness and collected data on agricultural activity frequency through questionnaires. Multivariate logistic regression analyses examined the association between agricultural activities and loneliness, controlling for demographic and health-related variables. Results Among 647 participants, higher frequencies of agricultural activities were significantly associated with increased loneliness, especially for individuals engaging in agriculture four to five times weekly or daily. Engaging in agricultural activities four to five times weekly and daily significantly increased the likelihood of higher loneliness levels, with odds ratios (OR) of 1.80 (p = 0.039) and 2.47 (p < 0.01), respectively, when compared to engagement less than once a week. Age emerged as an influential factor, with individuals aged 75 and older showing increased odds of experiencing higher loneliness (OR 1.56, p = 0.025). Conclusion The study underscores the dual nature of agricultural engagement in rural communities, highlighting its role in both supporting physical health and contributing to social isolation. These findings advocate for developing targeted interventions that mitigate loneliness among rural populations, suggesting the need for a balanced approach that encompasses social and healthcare strategies to enhance the overall well-being of individuals engaged in agriculture.

Factors affecting the duration of initial medical care seeking among older rural patients diagnosed with rheumatoid arthritis: a retrospective cohort study.

BACKGROUND: Early diagnosis and treatment of rheumatoid arthritis (RA) are essential to prevent progressive joint destruction and improve the quality of life (QOL) of patients. This study aimed to identify the factors associated with the duration from symptom onset to seeking initial medical care among older rural patients diagnosed with RA. METHODS: This retrospective cohort study was conducted in Unnan City, Japan, using electronic patient records. Data from patients aged > 65 years, who were admitted to the Unnan City Hospital between April 2016 and March 2021, were analyzed. The primary outcome was the duration from symptom onset to the initial visit to the medical institution. Demographic factors, laboratory data, and data on symptoms were collected and analyzed using statistical tests and regression models. RESULTS: In total, 221 participants were included in this study. The longer duration from symptom onset to medical care usage was significantly associated with age (adjusted odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.03-1.15), isolated conditions (adjusted OR: 4.45, 95% CI: 1.85-10.70), and wrist symptoms (adjusted OR: 3.22, 95% CI: 1.44-7.17). Higher education level and alcohol consumption were also associated with the duration from symptom onset to medical care usage. CONCLUSIONS: Older age, isolated conditions, and specific joint symptoms were significant factors influencing delays in seeking medical care among older rural patients with RA. Interventions to improve health literacy, increase social support, and raise awareness of RA symptoms are essential for expediting diagnosis and improving patient QOL. Further research is needed to explore additional psychosocial factors and beliefs that affect health-seeking behaviors in patients with RA.

Giant Cell Arteritis With Sepsis-Like Symptoms in an Elderly Man: A Case Report.

This case report details the diagnostic challenge and management of an 88-year-old man who presented to a rural Japanese community hospital with sepsis-like symptoms, initially suspected of acute bacterial cholangitis based on his physical and laboratory findings. Despite the antibiotic treatment of tazobactam and piperacillin, the patient's symptoms persisted, leading to further investigations that revealed no signs of infection but notable aortic arch wall thickening on contrast-enhanced computed tomography scans. These findings, combined with the patient's clinical presentation and lack of antibiotic response, redirected the diagnosis toward giant cell arteritis (GCA). The administration of prednisolone of 60 mg daily significantly alleviated symptoms and prevented potential severe complications such as blindness and irreversible neurological damage. This case underscores the importance of considering GCA in elderly patients presenting with systemic inflammatory symptoms and the necessity of timely intervention. It also highlights the challenges in managing high-dose steroid therapy in elderly patients and suggests the potential benefits of integrating immunosuppressants to reduce steroid dependency. This report emphasizes the need for heightened awareness and a comprehensive diagnostic approach in atypical presentations of GCA, particularly in geriatric populations within resource-limited healthcare settings.

The Association Between Community Dialogue and Loneliness in Rural Japanese Communities: A Cross-Sectional Study.

Introduction This investigation explores the influence of community dialogue on loneliness within rural Japanese communities amidst the backdrop of globalization, urbanization, and technological shifts. Highlighting the significance of both informal and formal community dialogues, the study aims to bridge the gap in empirical evidence regarding the role of these interactions in enhancing social cohesion and mitigating loneliness, particularly in rural areas facing demographic changes and privacy concerns. Method A cross-sectional study was performed in Unnan City, Japan, targeting individuals over 40 who regularly visited a local rural hospital. The study employed the Japanese version of the University of California, Los Angeles (UCLA) Loneliness Scale and questionnaires regarding the frequency of community dialogue, alongside examining participants' health and demographic details from hospital records. Analysis methods included t-tests, Mann-Whitney U tests, and multivariate logistic regression to examine the association between community dialogue frequency and loneliness. Results Among the 647 respondents, the participants' mean age was 71.26 years, with a male rate of 46.3%. The multivariate logistic regression analysis revealed that higher frequencies of community dialogue significantly reduce the odds of experiencing loneliness. Specifically, compared to individuals with the least frequency of community dialogue, those with more frequent and most frequent dialogues were significantly more likely to report higher loneliness levels, with odds ratios of 2.62 (95% CI: 1.60-4.29, p<0.01) and 4.11 (95% CI: 2.47-6.85, p<0.01), respectively. Additionally, an increase in BMI was inversely related to loneliness (OR: 0.95, 95% CI: 0.91-0.99, p=0.023), and individuals with a higher comorbidity index (CCI≥5) showed a decreased likelihood of reporting higher loneliness (OR: 0.64, 95% CI: 0.43-0.96, p=0.031). Conclusion This study shows compelling evidence that more frequent community interactions are inversely associated with feelings of loneliness. These findings suggest that initiatives to increase community dialogue need a nuanced approach to mental health and social cohesion in rural settings. The research further reveals an intriguing relationship between body mass index, the severity of comorbidities, and loneliness, offering insights into the complex interplay between physical health and social well-being. The importance of this study lies in its potential to inform policies and programs designed to foster social connections respecting rural contexts, thereby addressing the challenge of loneliness in rural communities.

Biopsychosocial Management of Rural Ankylosing Spondylitis in a Pregnant Woman: A Case Report.

In a rural Japanese setting, this case report delves into managing a post-partum woman diagnosed with ankylosing spondyloarthritis (AS), showcasing the complexities of balancing effective pain relief with breastfeeding. The study highlights a multifaceted approach that incorporates medical treatment, psychosocial support, and comprehensive patient education, which are essential in rural healthcare where resources may be scarce. Initially managed with diclofenac due to its safer profile for breastfeeding, the patient's treatment was eventually escalated to adalimumab, aligning with improved circumstances regarding breastfeeding. This case emphasizes the critical role of holistic, patient-centered care in family medicine, particularly for managing maternal and child health chronic conditions. It illustrates how integrating mental health support, acknowledging patient fears, and educating families can significantly enhance patient care and outcomes. Through this approach, the report advocates for a broader application of family medicine principles to improve maternal and child health services in rural settings, demonstrating the importance of tailored healthcare strategies that consider patients' medical and emotional needs.

Drug-Induced Hypersensitivity Syndrome Due to Long-Term Usage of Methotrexate: A Case Report.

Methotrexate (MTX), a cornerstone treatment for rheumatoid arthritis (RA), is associated with drug-induced hypersensitivity syndrome (DIHS), including rare instances of methotrexate-induced pneumonitis. We report a significant case of a 65-year-old woman with RA, treated with MTX for over two decades, who presented with fever, headache, nausea, and malaise and was later diagnosed with DIHS, manifesting as pneumonitis and hepatosplenomegaly. Despite initial suspicion of bacterial pneumonia, her condition deteriorated, leading to the consideration of DIHS. The diagnosis was confirmed through a drug lymphocyte stimulation test (DLST), and she responded well to prednisolone. This case underlines the complexity of long-term MTX therapy, emphasizing the need for vigilance towards DIHS even after years of treatment. The findings prompt a reconsideration of ongoing treatments for RA, particularly in settings where long-term MTX use is prevalent. Early intervention and diagnostic tests like the DLST are crucial for preventing severe outcomes. This case adds to the growing evidence of MTX's potential for causing DIHS even in long-term usage. It stresses the importance of balancing therapeutic benefits with the risks of significant adverse reactions in stable RA patients.

A Case Report of Remitting Seronegative Symmetrical Synovitis With Pitting Edema Causing Severe Anemia, Acute Progressive Dementia, and Chronic Eczema in an Older Female.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is a type of seronegative arthritis characterized by a favorable prognosis (Remitting), absence of rheumatoid factor (Seronegative), symmetry (Symmetrical), and synovitis with pitting edema on the backs of the hands and feet. The cause of RS3PE syndrome remains unknown, but involvement of the immune system is suspected, and steroids are highly effective. Here, we present a case of an 86-year-old woman with severe anemia and bilateral lower limb edema accompanied by chronic eczema, considered to be caused by RS3PE syndrome. The patient's symptoms included bilateral lower limb edema, allergic rash, cognitive decline, and difficulty in moving, all of which were attributed to RS3PE syndrome. Given the variety of systemic symptoms associated with RS3PE syndrome, which can significantly impair the activities of daily living (ADLs) in the elderly, early detection and treatment are crucial.

Applying Advanced Practice Nurses in Rural Japan: A Mixed-Methods Perspective.

Introduction Rural hospitals, particularly those in geographically isolated regions like Shimane Prefecture, Japan, face significant healthcare delivery challenges. These include limited resources, an aging population, and a scarcity of healthcare professionals. Advanced practice nurses (APNs) have emerged as pivotal in addressing these gaps, offering specialized patient assessment, diagnosis, and management skills. This study aimed to evaluate the demand for APNs in rural community hospitals, focusing on the specific educational needs and clinical competencies required to improve healthcare outcomes in these settings. Method Employing a mixed-methods approach, this research combined qualitative insights from stakeholder interviews with quantitative data analysis of electronic health records (EHRs) at Unnan City Hospital. This sequential exploratory design aimed to capture comprehensive educational needs and outcomes, integrating the depth of qualitative data with the breadth of quantitative evidence to tailor a curriculum for APNs in rural healthcare contexts. Results The study revealed a critical demand for APNs skilled in managing common medical issues in rural settings, such as infections, circulatory failures, and respiratory problems. Stakeholder interviews highlighted the necessity for a curriculum that enhances clinical competencies and emphasizes soft skills like communication and leadership. An analysis of EHRs identified 21 specific diseases across six categories, underlining the importance of targeted education on these prevalent conditions. Conclusion The findings underscore the urgent need for specialized education programs for APNs in rural hospitals to address these communities' unique healthcare challenges. Developing a curriculum that focuses on clinical and soft skills essential for rural healthcare delivery can significantly enhance the quality of care. This study advocates for implementing such tailored educational programs to empower APNs, thereby contributing to healthcare equity and improving patient outcomes in rural settings.

The Association Between Community Participation and Loneliness Among Patients in Rural Community Hospitals: A Cross-Sectional Study.

Introduction Loneliness among adults is a critical public health issue, particularly in rural areas where social isolation can be more pronounced. Understanding the factors that influence loneliness can guide the development of effective interventions. This study explores the impact of demographic, health-related, and social participation factors on loneliness among rural Japanese adults, focusing on the role of community participation. Method This cross-sectional study was conducted with rural Japanese adults who regularly visited rural community hospitals. Data were collected on participants' demographic characteristics, health status, and social participation and analyzed using a multivariate logistic regression model to identify factors associated with higher levels of loneliness. The covariates included age, sex, body mass index (BMI), chronic health conditions, and community participation. Results The study found that community participation had a significant negative association with loneliness, with an odds ratio (OR) of 0.46 (p < 0.01), indicating that individuals engaged in community activities were substantially less likely to experience higher levels of loneliness. Higher BMI was associated with lower odds of loneliness (OR = 0.93, p < 0.02), suggesting a protective effect against loneliness. Conclusion The findings highlight the paramount importance of community engagement in mitigating loneliness among rural Japanese adults. The inverse relationship between BMI and loneliness suggests that BMI and social participation influence loneliness. These insights underscore the need for comprehensive interventions that promote community participation and address the multifaceted nature of loneliness. Future research should further explore the mechanisms through which community engagement and BMI impact loneliness to develop targeted strategies for improving the well-being of rural adults.

Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach.

BACKGROUND: Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients. METHODS: This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study. RESULTS: Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team. CONCLUSIONS: The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Frailty Syndrome in Rural Communities: A Narrative Review and Interviews With Rural Individuals.

Background With the global increase in aging populations, frailty syndrome, characterized by decreased strength, endurance, and physiological function, has become a critical issue. This study focuses on rural Japanese communities, where the prevalence of frailty syndrome can be notably high due to factors such as multimorbidity, polypharmacy, and a significant population of elderly individuals. This research addresses the gap in understanding frailty's manifestations and impacts in rural settings, considering unique challenges such as social isolation, limited healthcare access, and the broader social determinants of health. Methodology The study employs a narrative review with PubMed and a thematic analysis of semi-structured interviews with 21 elderly community workers in Unnan City. The analysis used the framework of frailty syndrome affected by physiological, social, psychological, and economic factors. The analysis focused on identifying themes related to the social determinants of health affecting frailty and potential solutions. Results The following five themes emerged from the analysis: Aging, Rural Contexts, Isolation, Lack of Knowledge of Frailty Syndrome, and Lack of Help-Seeking Behavior for Frailty Syndrome. Four solution-oriented themes were identified, namely, Public Dialogue and Educational Workshops, Frailty Syndrome Health Meetings, Social Engagement Activities, and Political Advocacy for Accessibility to Community Centers. These findings highlight the critical role of community engagement, education, and infrastructure improvements in addressing frailty syndrome in rural areas. Conclusions This study underscores the complexity of frailty syndrome in rural Japanese communities, emphasizing the need for targeted interventions that address the unique challenges faced by these populations. By fostering public dialogue, improving healthcare access, and enhancing social support, it is possible to mitigate the impacts of frailty syndrome and improve the quality of life for elderly residents in rural settings. This research contributes to a deeper understanding of frailty in aging societies and the importance of considering social determinants of health in developing effective solutions.

The Balance Between Intensive and Palliative Care in an Anti-melanoma Differentiation-Associated Gene 5 (MDA5) Antibody-Positive Acute Interstitial Pneumonia in a Nonagenarian: A Case Report.

This case report details the management of anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive acute interstitial pneumonia in a 93-year-old man, a condition characterized by rapid progression and high mortality. Despite the grim prognosis typically associated with this disease, especially in elderly patients, the subject of this report survived beyond the expected timeframe, illustrating the effectiveness of prompt and aggressive treatment strategies. Initially presenting with dyspnea, the patient's diagnostic process was challenging due to the absence of dermatomyositis (DM)-specific skin manifestations. However, early suspicion led to the identification of anti-MDA5 antibodies, confirming the diagnosis. The treatment regimen initiated with corticosteroid pulses, cyclophosphamide, tacrolimus, and high-dose gamma globulin therapy significantly improved the patient's respiratory conditions, giving the patient and his family time to decide on their palliative care. This approach underlines the importance of early diagnosis and the implementation of comprehensive treatment strategies in managing anti-MDA5 antibody-positive interstitial pneumonia. In this case, the successful outcome adds valuable insights into the potential for extending survival and enhancing the quality of life in elderly patients with this severe autoimmune condition, emphasizing the need for a proactive and aggressive approach to treatment.

Differentiation Between Disseminated Carcinomatosis of the Bone Marrow From Urothelial Cancer and Intravascular Large B-cell Lymphoma: A Case Report.

This case report describes a rare case of intravascular large B-cell lymphoma (IVLBCL), initially presenting with nonspecific symptoms of fever and fatigue, and tentatively diagnosed as disseminated carcinomatosis of the bone marrow originating from urothelial cancer in an 80-year-old woman. The patient's journey began with symptoms treated as common ailments and progressed through multiple differential diagnoses, including giant cell arteritis, TAFRO (thrombocytopenia, anasarca, fever, reticulin fibrosis, and organomegaly) syndrome, and disseminated carcinomatosis of the bone marrow originating from urothelial cancer due to the presence of systemic inflammation, anasarca, and elevated soluble interleukin 2 receptor levels, indicative of an intense immunological response. Despite initial treatments, her condition deteriorated, leading to further investigations that ultimately revealed the presence of malignant cells in the urine and bone marrow, confirming the diagnosis of IVLBCL. This case underscores the diagnostic challenges faced when elderly patients present with systemic inflammation and the critical need for thorough investigation beyond initial impressions. It highlights the importance of considering differentiation between disseminated carcinomatosis of the bone marrow and IVLBCL in the differential diagnosis of persistent inflammation, especially in cases where common causes have been excluded and the primary malignancy is not immediately apparent.

Multiple Ulcers in the Ileum and Lymphadenopathy Following the Usage of Methotrexate in a Patient With Rheumatoid Arthritis: A Case Report.

This case report aims to highlight a rare occurrence of severe anemia and lymphadenopathy secondary to methotrexate (MTX)-induced ileal mucosa damage in a patient with elderly onset rheumatoid arthritis (EORA). We present the case of a 72-year-old female with a history of EORA, treated with MTX, who exhibited hematochezia without accompanying pain, diarrhea, or known infectious contacts. Diagnostic investigations included imaging and endoscopic procedures. The patient's presentation of severe anemia was atypical, given the absence of significant pain or discomfort associated with EORA. The lack of active bleeding observed during endoscopy, coupled with multiple ileal ulcers, suggested a chronic progression of mucosal damage. Laboratory findings, including normal lactate dehydrogenase, soluble interleukin-2 receptor levels, and the absence of malignancy in mucosal biopsies, ruled out MTX-induced lymphoma. The patient's condition improved with the cessation of MTX and the introduction of symptomatic treatment and anemia management. This case underscores the need for vigilant monitoring and comprehensive evaluation in patients with RA, especially the elderly, treated with MTX. It also highlights the importance of considering drug-induced complications in the differential diagnosis of anemia. The case demonstrates the necessity of a personalized approach to treatment, emphasizing regular follow-ups and adjustments based on the patient's response to therapy. This report contributes to the growing body of evidence on the complexities of managing RA in the elderly, particularly regarding the side effects of common medications like MTX.

Effectiveness of Doctor Clerks Supporting Physicians' Work in Japan: A Systematic Review.

The burgeoning administrative workload on physicians in Japan's healthcare system has necessitated innovative approaches to optimize clinical care. Integrating doctor clerks, tasked with administrative and clerical duties, has emerged as a potential solution to alleviate this burden. This systematic review aims to evaluate the effectiveness of doctor clerks in improving physicians' working conditions and patient care quality. A comprehensive literature search was conducted using Ichushi Web and Google Scholar from January 2000 to September 2023. Data were extracted on publication year, study setting, department focus, work scope, and outcomes of doctor clerk implementation. The search identified 3570 studies, with 17 meeting the inclusion criteria. Most studies were performed in general hospitals with 76.5% (13/17). The studies regarding university hospitals were 17.6% (3/17). Only one study was performed in a community hospital with 5.9% (1/17). More than half of doctor clerks worked not explicitly allocated to one department and did their work not specific to one department with 52.9% (9/17). Three studies report that doctor clerks collaborate with orthopedic surgeons. Two studies report that doctor clerks collaborate with emergency medicine physicians. Each study reports that doctor clerks collaborate with respiratory or general medicine. The most frequent is document support, with 94.1% (16/17). The second most frequent working content is consultation support, with 47.1% (8/17). The third most frequently working content is ordering support, with 23.5% (4/17). Call response, secretary work, education support, research support, conference support, and other professional support are included, each with 5.9% (1/17). Regarding clinical outcomes, five studies assessed a reduction in physician paperwork time (29.4%). Four studies assessed the frequency of the contents of doctor clerks' work (23.5%). Four studies assessed the positive perception of physicians (23.5%). Four studies assessed the amount of the reduction in physicians' overtime work (23.5%). Three studies assess the amount of the reduction in hospital costs (17.6%). One study assessed part-time physicians' fatigue reduction (5.9%). Each study assessed the quality of patient care, such as doctor's clerk education for standardization, increase in the number of patients accepted, reduction in medical incidents, decrease in patient waiting time, and primary to tertiary prevention. Introducing doctor clerks in Japan's healthcare system shows promise in enhancing physicians' working conditions and potentially improving patient care. However, conclusive evidence on the impact on patient care quality necessitates further investigation, serving as a foundation for future policy and healthcare system optimization.