Type 2 Myocardial Infarction Caused by Orthostatic Hypotension With Post-transcatheter Aortic Valve Implantation: A Case Report.

This case report delineates the occurrence and management of type 2 myocardial infarction (MI) in an 89-year-old woman following transcatheter aortic valve implantation (TAVI). The patient, with a history of severe aortic stenosis, hypertension, dyslipidemia, and colorectal cancer, presented with nausea and significant hypotension. Initial assessments revealed elevated troponin levels, atrial fibrillation, and ST-segment depression, leading to a diagnosis of type 2 MI. This condition was attributed to the interplay between left ventricular hypertrophy, hypotension-induced dehydration, and increased myocardial oxygen demand. The patient with post-TAVI exhibited dynamic changes in cardiac hemodynamics, with improvements in left ventricular function but persistent hypertrophy and diastolic dysfunction. This state, combined with hypotension due to diuretic-induced dehydration and atrial fibrillation, precipitated a mismatch in myocardial oxygen supply and demand. The cessation of diuretics and initiation of rehydration therapy stabilized her condition, with subsequent normalization of troponin levels and blood pressure. This case highlights the complexity of managing type 2 MI in elderly patients post-TAVI. It underscores the importance of holistic consideration of both myocardial oxygen supply and demand factors, particularly in left ventricular hypertrophy and diastolic dysfunction. The multifactorial nature of type 2 MI necessitates a tailored approach to diagnosis and management, emphasizing the need for comprehensive post-procedural care in patients undergoing TAVI.

Roles of autophagy in killing of mycobacterial pathogens by host macrophages - Effects of some medicinal plants.

Autophagy is a cellular stress-induced intracellular process, through which damaged cellular components are decomposed via lysosomal degradation. This process plays important roles in host innate immunity, particularly the elimination of intracellular pathogens inside host macrophages. A more detailed understanding of the roles of autophagic events in the effective manifestation of macrophagic antimycobacterial activity is needed. Furthermore, the effects of medicinal plants on macrophagic autophagy response to mycobacterial infection need to be clarified. We herein examined the significance of autophagic events in the manifestation of host immunity during mycobacterial infection, by performing a literature search using PubMed. Recent studies demonstrated that autophagy up-regulated macrophage functions related to the intracellular killing of mycobacteria, even when pathogens were residing within the cytoplasm of macrophages. The majority of medicinal plants potentiated macrophagic autophagy, thereby enhancing their antimycobacterial functions. In contrast, most medicinal plants down-regulate the development and activation of the Th17 cell population, which reduces macrophage antimycobacterial activity. These opposing effects of medicinal plants on macrophage autophagy (enhancement) and Th17 cell functions (inhibition) may provide a plausible explanation for the clinical observation of their modest efficacy in the treatment of mycobacterial infections.

Decision-Making in the Admission of Older Patients: A Thematic Analysis From Multiple-Stakeholder Perspectives.

Introduction As rural healthcare systems grapple with an aging population, understanding the factors influencing hospital admission decisions for elderly patients is crucial. This study explores the complex interplay of medical, social, and psychological factors that shape these decisions, as perceived by multiple stakeholders, including physicians, patients, and their families. Method This study was conducted in Unnan City Hospital, a rural community hospital in Unnan, Japan, using a qualitative thematic analysis approach. Participants included general physicians, patients admitted more than once, and their families. One-on-one semi-structured interviews were conducted in Japanese, recorded, transcribed, and analyzed. The analysis focused on identifying themes that influence decision-making processes regarding the admission of elderly patients. The research team, comprising family medicine, public health, and community health care experts, ensured a multi-perspective approach through collaborative coding and discussion. Results Three primary themes emerged from the analysis: "dilemma between medical indications and social admissions," "risks and benefits of hospitalization in response to unpredictable changes in the elderly," and "social factors intertwined with the multilayered nature of hospital admission decisions." Physicians reported a conflict between their medical training and the social needs of patients, often leading to stress and negative emotions. The unpredictable health trajectories of elderly patients necessitated a nuanced risk-benefit analysis for hospitalization. In addition, social factors, such as bed availability, patient's living environment, and psychosocial contexts, significantly influenced admission decisions. Conclusion The study highlights the need for a more holistic approach to medical education and practice, especially in rural healthcare settings. Recognizing the complexity of factors influencing hospitalization decisions, including medical, social, and individual patient circumstances, is vital. The findings underscore the importance of integrating biopsychosocial aspects into the decision-making process for the hospitalization of elderly patients, advocating for patient-centered care that respects the unique challenges in rural healthcare environments.

Healthcare Profession Students' Motivations for Learning About Community Organizing: A Thematic Analysis.

Background Medical care now emphasizes community health, prevention, health promotion, and collaboration. Integrating medical students into community health initiatives enhances their community health and student skills. In an aging multicultural population, the involvement of healthcare professionals in community health management is vital. However, medical education in Japan lacks sufficient exposure to community health issues. A program in Shimane Prefecture aimed to address this gap by revolutionizing medical education through community organizations. Methods This study employed a reflexive thematic analysis based on relativist ontology and constructivist epistemology. Participants aspiring to be healthcare professionals from Japanese high schools and universities were recruited from rural Shimane Prefecture. Computer-based questionnaires were used to collect data on participants' reasons, motivations, and visions for community-organizing education. The thematic analysis followed Braun and Clarke's approach and involved systematic coding, theme identification, and refinement. Results Three themes emerged from the analysis. In expanding hopes for unknown potential, participants sought improved communication skills, real-world understandings, and fresh perspectives and aimed to promote personal growth through community engagement. In acquiring activeness and new perspectives through connections with peers, hands-on learning and collaboration with peers with shared interests were motivating factors. Participants sought to generate inquiries and discover their activities. Regarding the desire to connect with diverse individuals driven by a strong curiosity about the community, participants aimed to learn community engagement techniques, understand community involvement methods, and explore the relationship between social issues and health. Conclusion Community-organizing education plays a pivotal role in shaping future healthcare professionals. Our analysis underscores the need for curriculum reform, including experiential learning and peer interaction, to facilitate a comprehensive understanding of health and community dynamics. Future studies should assess the long-term impacts of these experiences on students' careers and community health to contribute to advancements in medical education and community-oriented healthcare professionalism.

Atypical Adult Still's Disease Complicated by Hemophagocytic Syndrome in an Older Patient: A Case Report.

Hyperferritinemia can occur in various diseases, making the differential diagnoses diverse and often fatal. The macrophage-activated syndrome (MAS) is a differential diagnosis of hyperferritinemia in which systemic macrophages are activated and cause various symptoms. Many cases are complicated by hemophagocytic syndrome, causing pancytopenia, which can be fatal. Furthermore, it is challenging to diagnose hyperferritinemia in elderly patients, and the disease may develop into a fever of unknown origin. We report the case of a 93-year-old man with aspiration pneumonia, followed by intermittent prolonged fever complicated by abnormal hyperferritinemia and leukopenia. Based on his general condition, he was diagnosed with atypical adult Still's disease and treated with steroid pulses and tocilizumab, temporarily relieving his symptoms. However, the patient eventually developed sepsis and could not be saved. Diagnosis of hyperferritinemia in the elderly population is complex and requires immediate attention. However, invasive intervention may lead to the deterioration of an elderly patient's condition. In the context of medical care for the elderly at a community hospital, it is necessary to provide comprehensive care for those in critical condition, considering the degree of invasiveness of examinations and procedures.

The Association Between Vitamin B1 Deficiency and Anemia Among Elderly Patients at a Rural Hospital in Japan: A Cross-Sectional Study.

Background and objective Vitamin B1 deficiency can cause a variety of abnormalities in the neuropsychiatric, cardiovascular, and other systems. This condition can be rapidly corrected and prevented from progressing to irreversible sequelae through vitamin B1 supplementation. Therefore, early detection of and intervention in vitamin B1 deficiency are essential. We have previously demonstrated an association between vitamin B1 deficiency and appetite loss in hospitalized older adult patients in rural Japan. This study aimed to examine the additional predictors of vitamin B1 deficiency in patients with appetite loss and other symptoms suggestive of vitamin B1 deficiency. Material and methods This cross-sectional study involved 519 patients admitted to a rural hospital between April 2020 and March 2022. Data on vitamin B1 levels, age, sex, BMI, albumin levels, functional independence measure (FIM), hemoglobin levels, Charlson Comorbidity Index (CCI), and medications were collected from electronic medical records. Vitamin B1 deficiency was defined as serum vitamin B1 level <20 µg/dL. Data were analyzed using the Mann-Whitney U test, Student's t-test, and chi-square test, followed by multivariate logistic regression to examine the predictors of vitamin B1 deficiency. Results A total of 113 patients (21.5%) were found to be vitamin B1-deficient. Multivariate logistic regression showed that anemia was significantly associated with vitamin B1 deficiency [adjusted odds ratio (AOR): 1.71, 95% confidence interval (CI): 1.07-2.73, p<0.05]. Conclusion Based on our findings, anemia is significantly associated with vitamin B1 deficiency in hospitalized Japanese patients living in rural areas. Therefore, physicians should be mindful of the possibility of vitamin B1 deficiency in hospitalized patients with anemia.

Importance of Inclusive Education in General Medicine Through the Perception of Medical Trainees: A Thematic Analysis.

Background General medical education plays a pivotal role in ensuring holistic care in the context of rapidly aging populations. Japan's demographic trends underscore the significance of general medicine in elevating community care standards. Understanding and catering to the aspirations, perceptions, and ideals of medical students and residents can significantly augment the effectiveness of general medicine education. This research aimed to explore the perspectives of medical students on the ideal tenets of general medicine education in rural Japan. Method A qualitative approach was employed, focusing on medical students and residents with a keen interest in general medicine, all of whom underwent training at a rural-based Japanese hospital. Through semi-structured interviews, insightful data were garnered and subsequently subjected to a comprehensive thematic analysis. Results The thematic analysis unearthed three core themes: commitment of educators in valuing learner diversity, promotion and understanding of general medicine, and inclusivity and diversity in educational institutions. The first highlighted the centrality of educators' sincerity, emphasizing the importance of genuine, sustained interactions that foster mutual respect and collaborative learning. The second theme underscored the need to elucidate the intrinsic value and modern-day relevance of general medicine, emphasizing its deep roots in community-based practices and its continuity with long-standing medical traditions. The third theme spotlighted the crucial role of comprehensive medical education in fostering enriching dialogues, embracing varied learning experiences, and capitalizing on the distinctive strengths of educational institutions. Conclusion These findings underscore the pivotal shift required in pedagogical approaches to comprehensive medical education. A genuine collaborative educator-learner relationship, the reframing of general medicine's significance rooted in community welfare, and a strong emphasis on inclusivity and dialogue form the cornerstones of these insights. This study provides a touchstone for restructuring educational strategies, aiming for a more integrated, genuine, and encompassing framework that is particularly vital for the effective propagation of general medicine in regions such as Japan.

Utilizing Learn-to-Rank Systems for More Effective Diagnosis in Rural Family Medicine.

This editorial investigates the development and efficacy of Japanese learn-to-rank approach systems in family medicine, emphasizing their establishment by Dr. Keijiro Torigoe and their significance in rural community hospitals. Initiated in 1977, Dr. Torigoe's innovative system integrated international medical knowledge with technology, yielding a comprehensive database of 7,000 registered diseases. These learn-to-rank approaches, notably the listwise method, address technological gaps in extracting data on differential diseases and enhance the predictive performance of clinical decision support systems, offering a holistic, culturally resonant healthcare approach. They are especially vital in rural medicine, aiding in managing the volatility, uncertainty, complexity, and ambiguity prevalent among older patients, streamlining diagnoses, and improving healthcare delivery in resource-constrained settings. In conclusion, integrating Japanese learn-to-rank approach systems is pivotal in revolutionizing disease diagnosis, catering to diverse rural health needs, and fostering sustainability in rural healthcare systems. By harmonizing medical insights with innovation, they demonstrate the potential for a comprehensive and contextually relevant approach to healthcare in Japan.

Staphylococcus epidermidis Bacteremia in an Older Patient With Guillain-Barré Syndrome With Fever of Unknown Origin: A Case Report.

Guillain-Barré syndrome (GBS) is an immune-mediated disorder that affects the peripheral nerves, often leading to weakness, numbness, and paralysis. Although GBS does not induce immunosuppression, severe cases can render patients vulnerable to infection due to various complications. We present the case of a 70-year-old woman who developed GBS following a Mycoplasma infection. The patient's prolonged GBS symptoms led to an immunocompromised state, resulting in sepsis due to bacteremia caused by methicillin-resistant Staphylococcus epidermidis. Respiratory muscle paralysis necessitated intubation and mechanical ventilation, predisposing the patient to aspiration pneumonia. Prolonged hospitalization increases the risk of infection, as exemplified by catheter-related bloodstream infections and respiratory bacterial colonization. Although GBS does not inherently suppress immunity, its complications, such as musculoskeletal and respiratory failure, can mimic immunodeficiency, necessitating comprehensive management. A system-based approach should address neurological deficits and potential complications, emphasizing collaboration among medical specialties. This case highlights the importance of recognizing GBS-related challenges and adopting a holistic strategy for effective patient care.

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.

Complicated Japanese Spotted Fever With Meningitis in an Older Patient: A Case Report.

Japanese spotted fever (JSF) poses a significant public health challenge, mainly due to its atypical presentation in specific demographics. This report details a unique case of JSF in an 89-year-old female who was admitted to a rural hospital exhibiting generalized pain and rapid cognitive decline but no rash. Initially misdiagnosed as polymyalgia rheumatica, her condition was complicated by thrombocytopenia and altered mental state, prompting consideration of tick-borne illnesses. Subsequent serological analysis confirmed JSF despite the absence of its hallmark rash. The patient's condition escalated to include bacteremia and aseptic meningitis. Treatment involved a regimen of minocycline and meropenem, along with endoscopic cauterization of a bleeding rectal ulcer. After treatment, the patient showed improvement and was transferred for rehabilitation. This case highlights the criticality of considering JSF in elderly patients within endemic areas, even when classic symptoms like erythema and petechiae are absent. It underscores the necessity for broad diagnostic perspectives, especially in atypical presentations, and the integration of comprehensive care approaches. The involvement of caregivers and relatives in early detection and seeking medical care promptly is crucial. The report illustrates the complexities in diagnosing and managing advanced JSF cases and stresses the importance of early serological testing and adaptive treatment strategies in managing such challenging cases.

Integrating Clinical and Socio-Environmental Approaches in Managing Rheumatoid Arthritis With Social Determinants of Health: A Case Study of an Elderly Patient in Rural Japan.

Rheumatoid arthritis (RA) poses significant management challenges, especially in elderly patients living in rural areas with limited access to health care. This case report illustrates an integrative approach to managing RA, emphasizing the interplay of clinical, social, and environmental factors. A 72-year-old woman in a rural Japanese setting presented with progressive, widespread joint pain, initially self-managed with over-the-counter medications. Her condition, complicated by socioeconomic constraints and limited access to health care, necessitated a comprehensive management strategy. Clinical examination revealed bilateral joint tenderness, swelling, and high titers of rheumatoid factor and anti-citrullinated protein antibodies, confirming RA. Treatment included methotrexate and prednisolone, complemented by lifestyle modifications. Interdisciplinary collaboration among healthcare professionals, including nutritionists and physiotherapists, facilitated her management. The patient's care was guided by the chronic care model and the ecological model, addressing her clinical needs and socio-environmental context. This holistic approach resulted in improved clinical outcomes and enhanced quality of life. This case highlights the importance of a patient-centered, multidisciplinary approach in managing RA in rural settings. Integrating clinical management with an understanding of social determinants and patient empowerment is crucial for effective treatment. The case underscores the need for adaptable healthcare strategies that are sensitive to the unique challenges faced by elderly patients in rural communities.

Implementation of the Principles of Family Medicine in Modern Family Medicine Education Needing System-Specific Approaches.

Family medicine is a key specialty in primary healthcare worldwide. Medical students and residents learn family medicine in medical schools and hospitals. Modern family medicine education curricula have changed because of the increase in the number of organ specialists. Family physicians have more comprehensive training in patients, medicine, and social issues than in the past. Family physicians need to adapt to changing circumstances, but he needs to practice comprehensive and holistic medicine, as most of the time, family physicians are the first point of contact both in urban and rural setup. In 1979, McWhinney proposed nine principles of family medicine to which family physicians should adhere when providing care to patients in their communities. A review of and reflection on these principles has clarified that the principles should be more emphasized and practiced. Besides, respectful approaches by different family physicians are essential. To adapt to changing healthcare conditions, family medicine education can focus more on person-centered care and healthcare systems as system-specific specialists, respect the differences in healthcare provision between urban and rural areas, and motivate medical students and residents to become family physicians.

Association between Self-Medication for Mild Symptoms and Quality of Life among Older Adults in Rural Japan: A Cross-Sectional Study.

Self-medication, a help-seeking behavior to control individual symptoms, can be promoted to prevent the overuse of medical care and improve self-management among older adults. However, evidence regarding the association between self-medication and quality of life (QOL) is lacking. The purpose of this study is to investigate the association between QOL and the usage of self-medication among rural older adults. This cross-sectional study included participants older than 65 years in rural Japanese communities. Data were collected using a questionnaire regarding self-medication trends, the EQ-5D-5L to assess QOL, and a demographics questionnaire. Participants were divided into exposure and control groups based on their tendencies toward self-medication usage. Differences in the demographics between groups were adjusted using propensity score matching. Results: The health status in the exposure group was statistically significantly better than that in the control group in the dimensions of movement, self-care, and usual activities. Conversely, the pain/discomfort and anxiety/depression dimensions were not statistically significantly different. The quality of self-medication behaviors for mild symptoms can be improved with practical knowledge of and access to home remedies and over-the-counter drugs. Educational interventions and system development for better self-medication for mild symptoms and medical care for critical symptoms in rural contexts can be effective in improving QOL among rural older adults.

Changes in the Comprehensiveness of Rural Medical Care for Older Japanese Patients during the COVID-19 Pandemic.

Help-seeking behaviors (HSBs) refer to how people use lay and medical care to address their symptoms and diseases. The COVID-19 pandemic may have changed older, rural patients' preferences and experiences regarding HSBs, thereby, affecting the comprehensiveness of medical support for communities. This study identified changes in the comprehensiveness of medical care for older, rural patients, who are often dependent on others for accessing medical services. This observational study was performed with patients who lived in Unnan City. Patients' dependency and changes in comprehensiveness of medical services were assessed and calculated. The total usage of medical care decreased from 2018 to 2020 at all medical care levels. The proportion of patients who received comprehensive care was higher in 2020 than in 2018, at all care levels. At care dependent levels 3 to 5, the differences in the proportions were statistically significant. This study illustrates an association between the COVID-19 pandemic and the proportion of comprehensiveness of medical care among older rural patients with a decrease in medical care usage. Moreover, an improved proportion of comprehensiveness of medical care leads to appropriate HSBs. Going forward, HSBs and patient-centered care should be promoted by policy makers.

Comprehensive Care through Family Medicine: Improving the Sustainability of Aging Societies.

Comprehensive care through family medicine can enhance the approach to multimorbidity, interprofessional collaboration, and community care, and make medical care more sustainable for older people. This study investigated the effect of implementing family medicine and the comprehensiveness of medical care in one of the most rural communities. This implementation research used medical care data from April 2015 to March 2020. Patients' diagnoses were categorized according to the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). In 2016, family medicine was implemented in only one general hospital in Unnan. The comprehensiveness rate improved in all ICD-10 disease categories during the study period, especially in the following categories-infections; neoplasms; endocrine, nutritional, and metabolic diseases; mental disorders; nervous system; circulatory system; respiratory system; digestive system; skin and subcutaneous tissue; musculoskeletal system and connective tissue; and the genitourinary system. Implementing family medicine in rural Japanese communities can improve the comprehensiveness of medical care and resolve the issue of fragmentation of care by improving interprofessional collaboration and community care. It can be a solution for the aging of both patient and healthcare professionals. Future research can investigate the relationship between family medicine and patient health outcomes for improved healthcare sustainability.

Immunoadjunctive Therapy against Bacterial Infections Using Herbal Medicines Based on Th17 Cell-mediated Protective Immunity.

One of the major health concerns in the world is the global increase in intractable bacterial infectious diseases due to the emergence of multi- and extensively drug-resistant bacterial pathogens as well as increase in compromised hosts around the world. Particularly, in the case of mycobacteriosis, the high incidence of tuberculosis in developing countries, resurgence of tuberculosis in industrialized countries, and increase in the prevalence of Mycobacterium avium complex infections are important worldwide health concerns. However, the development of novel antimycobacterial drugs is currently making slow progress. Therefore, it is considered that devising improved administration protocols for clinical treatment against refractory mycobacteriosis using existing chemotherapeutics is more practical than awaiting the development of new antimycobacterial drugs. The regulation of host immune responses using immunoadjunctive agents may increase the efficacy of antimicrobial treatment against mycobacteriosis. The same situations also exist in cases of intractable infectious diseases due to common bacteria other than mycobacteria. The mild and long-term up-regulation of host immune reactions in hosts with intractable chronic bacterial infections, using herbal medicines and medicinal plants, may be beneficial for such immunoadjunctive therapy. This review describes the current status regarding basic and clinical studies on therapeutic regimens using herbal medicines, useful for the clinical treatment of patients with intractable bacterial infections. In particular, we focus on immunoadjunctive effects of herbal medicines on the establishment and manifestation of host antibacterial immunity related to the immunological roles of Th17 cell lineages.

Clinical and Basic Studies on Therapeutic Efficacy of Herbal Medicines against Mycobacterial Infections.

The high incidence of tuberculosis (TB) in developing countries, the resurgence of TB in industrialized countries, and the worldwide increase in the prevalence of Mycobacterium avium complex infections are important global health concerns. However, the development of novel antimycobacterial drugs is currently making very slow progress. Therefore, it is considered that devising improved administration protocols for clinical treatment against intractable mycobacteriosis using existing chemotherapeutics is more practical than awaiting the development of new antimycobacterial drugs. The regulation of host immune responses using immunoadjunctive agents may increase the efficacy of antimicrobial treatment against mycobacteriosis. In particular, the mild and long-term up-regulation of host immune reactions against mycobacterial pathogens using herbal medicines may be beneficial for such immunoadjunctive therapy. This review focuses on the current status regarding basic and clinical studies on protocols using herbal medicines, including medicinal plants, useful for the clinical treatment of intractable mycobacterial infections.

History of glutamate production.

In 1907 Kikunae Ikeda, a professor at the Tokyo Imperial University, began his research to identify the umami component in kelp. Within a year, he had succeeded in isolating, purifying, and identifying the principal component of umami and quickly obtained a production patent. In 1909 Saburosuke Suzuki, an entrepreneur, and Ikeda began the industrial production of monosodium l-glutamate (MSG). The first industrial production process was an extraction method in which vegetable proteins were treated with hydrochloric acid to disrupt peptide bonds. l-Glutamic acid hydrochloride was then isolated from this material and purified as MSG. Initial production of MSG was limited because of the technical drawbacks of this method. Better methods did not emerge until the 1950s. One of these was direct chemical synthesis, which was used from 1962 to 1973. In this procedure, acrylonitrile was the starting material, and optical resolution of dl-glutamic acid was achieved by preferential crystallization. In 1956 a direct fermentation method to produce glutamate was introduced. The advantages of the fermentation method (eg, reduction of production costs and environmental load) were large enough to cause all glutamate manufacturers to shift to fermentation. Today, total world production of MSG by fermentation is estimated to be 2 million tons/y (2 billion kg/y). However, future production growth will likely require further innovation.