Report of Weil's disease with a fatal course triggered by Jarisch-Herxheimer reaction.

Leptospirosis, a zoonotic disease characterized by a spectrum of influenza-like symptoms, can manifest as severe cases so called Weil's disease. Early diagnosis and treatment are crucial to avoid the potentially fatal course of the disease. Within 24 hours of the initial administration of antibiotics, patients may experience the Jarisch-Herxheimer reaction (JHR), characterized by chills, fever, hypotension, and impaired consciousness. The Okinawa Prefecture, where our hospital is situated, boasts the highest incidence rate of leptospirosis among all regions in Japan. This reports our encounter with the initial leptospirosis case after a period of 16 years within the Okinawa Prefecture. This case exhibited JHR and required the utilization of noradrenaline (NA). Despite evidence indicating that JHR does not correlate with mortality, we contend that diagnosis of Weil's disease necessitates admission to an intensive care unit (ICU) and vigilant monitoring for JHR, as it may result in impairment of general condition and fatal outcome, as observed in our case.

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.

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.

The Relationship Between the Presence of White Nails and Readmission Among Rural Older Admitted Patients: A Prospective Cohort Study.

Background Nail changes can indicate systemic changes within the body. According to previous studies, white nails, characterized by the whitening of the proximal nails with the absence of a lunula, were related to in-hospital mortality in rural community hospitals. Hence, this study aimed to investigate the relationship between the presence of white nails and readmissions among rural older patients who had previously been discharged from rural community hospitals. Methodology The relationship between white nails and readmissions among admitted older patients discharged from community hospitals was investigated. This was a single-center prospective study. All patients >65 years admitted from April 2020 to March 2021 and readmitted between April 2020 and June 2021 were included in the study. Upon admission, all patients' nails were evaluated by trained evaluators for whitening. The presence of white nails was correlated with readmission using a multivariate logistic regression model. Results Approximately 28.7% of all participants were readmitted to the hospital during the study period; 41.1% had white nails, and 24.6% did not. Cox hazard model was used to analyze the relationship between readmission and white nails. Of all 637 participants, 24.8% had white nails. Significant variables for readmission were cancer (hazard ratio, HR = 1.52, p = 0.033), dementia (HR = 1.52, p = 0.037), heart failure (HR = 1.53, p = 0.033), home discharge (HR = 0.32, p ≤ 0.001), duration of previous hospitalization (HR = 0.99, p = 0.0026), and white nails (HR = 2.07, p ≤ 0.001). Conclusions White nails may be associated with readmission among previously admitted older patients. Identifying white nails in older admitted patients may enhance awareness of readmission risk; however, this needs further research.

Older People's Help-Seeking Behaviors in Rural Contexts: A Systematic Review.

Help-seeking behavior (HSB) is vital for older people to sustain their health. As people in aging societies increasingly demand management of their multiple symptoms, communities should encourage HSBs. In rural communities, insufficient healthcare and human resources influence older people's health. However, no related comprehensive evidence exists so far. This study investigates the present condition of older people's HSBs in rural contexts in aging societies. We conducted a systematic review by searching six databases (PubMed, Cochrane Library, EMBASE, Medline, and Web of Science) for original studies regarding HSBs of older people in rural contexts published until January 2022. Extracted articles were analyzed based on participants, settings, HSB causes and contents, and older people's HSB outcomes in rural contexts. Sixteen studies were included in the systematic review: seven investigated the associations between HSBs and participants' backgrounds, and three the quality of life. Six studies investigated HSB perception, diagnosis, clarifying HSB contents, professional care trend, self-rated health, and mortality. Unlike few studies investigating the association between HSBs and health-related outcomes, this systematic review explains the current evidence regarding rural older people's HSBs. Due to insufficient evidence from longitudinal studies in clarifying interventions for effective HSBs, future studies should use observational and interventional designs.

The Persistent Approach to Diagnose Infectious Hepatic Cysts in a Patient With Recurrent Fever: A Case Report.

Diagnosing infectious hepatic cysts (IHCs) can be challenging. Moreover, patients with IHCs may present with various symptoms. Diagnosis of IHCs can be even more difficult in patients with multiple liver cysts. For appropriate diagnosis, the detection of infectious sections in the liver is essential. However, diagnosing and determining definite treatments for patients with IHCs can be particularly challenging when they have polycystic liver disease. We present a case of a 70-year-old man who visited a rural community hospital with a primary complaint of recurrent fever and pain in the right upper quadrant. Based on his clinical history, physical examination findings, and imaging findings after three admissions, he was diagnosed with IHCs. This case demonstrates the challenges in diagnosing IHCs in patients with multiple hepatic cysts and highlights the necessity of a careful follow-up of clinical histories and findings of definitive imaging tests in the diagnosis of IHCs in patients with recurrent fever. To diagnose IHCs effectively, a comprehensive approach including history taking, physical examination, and diagnostic testing, is essential. IHCs should be considered by physicians when patients present with recurrent fever. To avoid missing IHCs, physicians in outpatient departments should continuously follow up on patients' IHC-related symptoms such as fever and right upper quadrant pain.

The Relationship between the Presence of White Nails and Mortality among Rural, Older, Admitted Patients: A Prospective Cohort Study.

White nails are a sign of various physical deteriorations, including poor nutrition, organ damage, and aging. During a physical examination, white nails can be a helpful health indicator in older patients with vague and multiple symptoms. In this prospective cohort study of patients admitted to the Department of General Medicine in a rural community hospital, we investigated the relationship between white nails and patient mortality. Patient data, including age, sex, condition, and bloodwork results, were collected. Trained family physicians confirmed the presence of white nails. Logistic regression analysis was performed to determine the relationship between white nails and death during hospitalization. Of 711 study participants, 74 died during hospitalization. White nails, male sex, and caregiver dependence were associated with high in-hospital mortality (odds ratio (OR) = 3.47, p < 0.001; OR 2.05, p = 0.01; OR 1.92, p = 0.049, respectively). High albumin concentration was associated with low in-hospital mortality (OR = 0.44, p < 0.001). White nails, along with serum albumin concentration, male sex, and caregiver dependence, are associated with mortality. The identification of white nails can predict the deterioration of patients. Various professionals should learn to identify the presence of white nails to facilitate the care of elderly patients.

Family Medicine Education at a Rural Hospital in Japan: Impact on Institution and Trainees.

Family medicine is vital in Japan as its society ages, especially in rural areas. However, the implementation of family medicine educational systems has an impact on medical institutions and requires effective communication with stakeholders. This research-based on a mixed-method study-clarifies the changes in a rural hospital and its medical trainees achieved by implementing the family medicine educational curriculum. The quantitative aspect measured the scope of practice and the change in the clinical performance of family medicine trainees through their experience of cases-categorized according to the 10th revision of the International Statistical Classification of Disease and Related Health Problems. During the one-year training program, the trainees' scope of practice expanded significantly in both outpatient and inpatient departments. The qualitative aspect used the grounded theory approach-observations, a focus group, and one-on-one interviews. Three themes emerged during the analysis-conflicts with the past, driving unlearning, and organizational change. Implementing family medicine education in rural community hospitals can improve trainees' experiences as family physicians. To ensure the continuity of family medicine education, and to overcome conflicts caused by system and culture changes, methods for the moderation of conflicts and effective unlearning should be promoted in community hospitals.

What resources do elderly people choose for managing their symptoms? Clarification of rural older people's choices of help-seeking behaviors in Japan.

BACKGROUND: Appropriate help-seeking behavior (HSB) that involves lay and professional care may moderate the usage of medical resources and promote good health, especially among the rural elderly. However, there is little evidence regarding the rural elderly's HSB choices for mild symptoms. Therefore, this study attempts to bridge this gap. METHODS: The participants were patients living in rural areas and over the age of 65, who attended Japanese clinics and general hospitals. In Phase 1, monthly diaries and one-on-one interviews about their mild symptoms and HSB were used to establish HSB items and assess its content validity. Content analysis helped determine the items. In Phase 2, participants were asked to complete the list to measure HSB. The answers to the list and HSB mentioned in the diaries were compared to evaluate concurrent validity. Retests were conducted to examine the content's reliability and test-retest reliability. RESULTS: Phase 1 included 267 participants (average age = 75.1 years, standard deviation [SD] = 4.3; 50.1% male). The diary collection rate was 97.6%. Of the participants, 70.4% used lay care and 25.4% used professional care. Content analysis identified eight types of lay care and four types of professional care. Phase 2 included 315 participants (average age = 77.7 years, SD = 8.27; 46.0% male). In terms of validity, the results of the list and the diaries were correlated (Spearman r 0.704; p < 0.001). The most common behavior with mild symptoms was consulting with primary care physicians, followed by self-care and using home medicine. The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care. CONCLUSIONS: The choices of HSB for mild symptoms clarified identified in this study have high validity and reliability. Therefore, it can be used to assess the relationships between HSB and health conditions and the effectiveness of health promotion on rural older people's HSB.

Effects of Implementation of Infection Control Measures against COVID-19 on the Condition of Japanese Rural Nursing Homes.

This study aimed to clarify the effect of coronavirus disease (hereafter, COVID-19) control on patients' health conditions and staff's working conditions in rural nursing homes. An interventional study including all staff and patients in a rural nursing home was performed from 1 April 2019 to 31 March 2021. Infection control measures against COVID-19 were initiated on 1 April 2020. The primary outcome was the frequency of patients' medical care visits to the outpatient and emergency departments. The secondary outcome was the number of days-off taken by staff. Each group (pre- and post-COVID-19 control groups) had 48 participants. The number of visits to the outpatient department reduced from the pre-COVID-19 to post-COVID-19 control period the difference in number of visits to the emergency department was not significant, due to the low statistical power. The number of days-off taken by the staff was increased from the pre-COVID-19 to post-COVID-19 control period. This is the first study investigating COVID-19 control measures in a rural nursing home. It may help reduce the number of patient visits to medical facilities without increasing the risk of emergencies. A strict health check of the staff can allow staff to take more days off in rural contexts.

Fears Related to COVID-19 among Rural Older People in Japan.

Coronavirus disease 2019 (COVID-19) has affected people's social lives by inhibiting their movement; this seriously impacts the lives of older people in particular. Rural older people may have been particularly affected because they live dispersedly and in isolation. This study explored rural older people's perceptions of how COVID-19 has impacted their social lives. This qualitative study assessed participants who were 65 years and older and residing in rural Japanese communities. Five focus group discussions were conducted with 53 participants to explore their perceptions and challenges during COVID-19. Data were analyzed using thematic analysis, and four themes were developed: the beginning of suffering, social cognitive suppression, reflection on rural contexts, and critical approaches to the pandemic based on rural standards. The daily activities of rural older people were suppressed due to social norms and pandemic-related standard precautionary measures based on urban areas. Specific infection control standards for rural areas and the provision of direct information to individuals in the community to sustain social support are needed. To effectively maintain rural social support, as well as the trust and accountability of rural citizens, constant dialog among local governments and rural citizens is required.

Association between transient appetite loss and vitamin B1 deficiency in elderly patients with suspected deficiency.

BACKGROUND: There is scarce evidence associating vitamin B1 levels and appetite loss duration in elderly patients with suspected B1 deficiency. We aimed to investigate this association in elderly hospitalized patients with suspected vitamin B1 deficiency in rural Japan. METHODS: This cross-sectional study evaluated 309 elderly patients (aged ≥ 65 years) admitted to one rural Hospital between April 2017 and March 2019. We collected data on vitamin B1 level, age, sex, body mass index, albumin levels, area of residence, long-term care, dependent conditions, activities of daily living, Charlson comorbidity index, and appetite loss from the patients' electronic medical records. Vitamin B1 deficiency was defined as serum vitamin B1 levels <20 µg/dL. Data were analyzed using the Mann-Whitney U, Student's t, and chi-square tests, followed by multivariable logistic regression, to examine the association between vitamin B1 deficiency and appetite loss. RESULTS: Eighty-eight (28.5%) patients had vitamin B1 deficiency. In multivariable logistic regression, appetite loss (for both < 1 and > 1 week) before admission to the hospital showed a significant association with vitamin B1 deficiency (adjusted odds ratio [AOR] =10.80, 95% confidence interval [CI]: 5.16-22.00, P < .001; and AOR = 5.77, 95% CI: 2.88-11.50, P < .001, respectively). CONCLUSIONS: Appetite loss is associated with vitamin B1 deficiency in elderly Japanese patients living in rural areas. Therefore, physicians should be aware of the possibility of vitamin B1 deficiency in elderly patients with appetite loss and focus on early intervention.

Improvement in palliative care quality in rural nursing homes through information and communication technology-driven interprofessional collaboration.

INTRODUCTION: Information and communication technology (ICT) can facilitate long-term care. In long-term care, effective communication among healthcare professionals is vital to reduce inappropriate emergency transfer and eventual death in hospitals. As nursing homes in rural areas lack adequate healthcare resources, ICT can reduce the burden on professionals, leading to adequate long-term care. This study investigated whether the application of ICT-based communication can reduce the number of emergency transportations to, and death in, hospitals in rural facilities. METHODS: This was an interventional study. Participants were patients living in a rural nursing home in the westernmost part of Unnan City in Shimane prefecture, Japan. The intervention group was defined as patients living therein after application of the ICT system and the control group as patients living therein before application of the ICT system. The primary outcome was the rate of emergency transportation to hospitals and the secondary outcome was the rate of death in the nursing home. RESULTS: The total number of participants was 96 (48 in the ICT usage group and 48 in the control group), and the average age of this sample was 89.5 years. The rate of emergency transportation was 54.2% (26/48) in the control group and 29.2% (14/48) in the intervention group (p=0.022). The rate of end-of-life care in the nursing home was 33.3% (3/9) in the control group and 84.6% (11/13) in the intervention group (p<0.001). CONCLUSION: ICT-driven nursing home care can reduce emergency transportation from nursing homes and enable patients in nursing homes to remain there longer, leading to an increase in end-of-life care in nursing homes, which provides hope to patients and their families. Therefore, these findings highlight that the continuous provision of ICT can facilitate end-of-life care in nursing homes.

Educational Intervention to Improve Citizen's Healthcare Participation Perception in Rural Japanese Communities: A Pilot Study.

In this mixed-methods study, we hypothesized that social cognitive theory (SCT)-based educational interventions for healthcare participation can improve the self-efficacy of older rural citizens in participating in their health management without any difficulties. Quasi-experimental study before and after SCT-based educational interventions and semi-structured interviews were conducted. Participants were Japanese elderly (>65 years) from rural communities. Propensity score matching was performed to estimate the effectiveness of educational interventions on participants' perception (intervention: n = 156; control: n = 121). Interview contents were transcribed verbatim and analyzed based on thematic analysis. The intervention group scored significantly higher than the control group for participation in planning and managing self-care. Interviews revealed three themes: ability to manage health conditions, relationship with medical professionals, and relationship among citizens. Participants reported difficulties in judging symptoms and communicating with medical professionals. Hierarchy and low motivation to participate in healthcare hindered collaboration. The findings suggest that SCT-based educational interventions can positively impact rural citizens' self-efficacy in healthcare participation.

The Uncertainty of COVID-19 Inducing Social Fear and Pressure on the Continuity of Rural, Community-Based Medical Education: A Thematic Analysis.

Rural community-based medical education (CBME) enriches undergraduate and postgraduate students' learning but has been impacted by the coronavirus disease 2019 (COVID-19) pandemic. We identified the challenges faced by stakeholders as well as the relevant solutions to provide recommendations for sustainable CBME in community hospitals during the COVID-19 pandemic. A total of 31 pages of field and reflection notes were collated through direct observation and used for analysis. Five physicians, eight nurses, one clerk, fourteen medical trainees, and three rural citizens were interviewed between 1 April and 30 September 2020. The interviews were recorded and their contents were transcribed verbatim and analyzed using thematic analysis. Three themes emerged: uncertainty surrounding COVID-19, an overwhelming sense of social fear and pressure within and outside communities, and motivation and determination to continue providing CBME. Rural CBME was impacted by not only the fear of infection but also social fear and pressure within and outside communities. Constant assessment of the risks associated with the pandemic and the implications for CMBE is essential to ensure the sustainability of CBME in rural settings, not only for medical educators and students but also stakeholders who administrate rural CBME.

The Contribution of Citizens to Community-Based Medical Education in Japan: A Systematic Review.

Community-based medical education (CBME) offers vital support to healthcare professionals in aging societies, which need medical trainees who understand comprehensive care. In teaching comprehensive care practices, CBME can involve citizens from the relevant community. This research synthesizes the impact of the involvement of communities on the learning of medical trainees in CBME. We conducted a systematic review, in which we searched ten databases from April 1990 to August 2020 for original articles in Japan regarding CBME involving citizens and descriptively analyzed them. The Kirkpatrick model was used to categorize the outcomes. Our search for studies following the protocol returned 1240 results; 21 articles were included in this systematic review. Medical trainees reported satisfaction with the content, teaching processes, and teachers' qualities. Medical trainees' attitudes toward community and rural medicine improved; they were motivated to become family physicians and work in communities and remote areas. This review clarified that citizen involvement in CBME had an effective impact on medical trainees, positively affecting perceptions of this type of education, as well as improving trainees' knowledge about and attitude toward community and rural medicine.

Effectiveness and Challenges in Local Self-Governance: Multifunctional Autonomy in Japan.

Community organizing with government support, termed local self-governance (LSG), is a form of policy decentralization for community wellbeing through solutions tailored to local issues. One form of LSG is multifunctional autonomy, in which citizens can comprehensively manage their communities with government support. This study clarified the effect of multifunctional autonomy on healthy life expectancy by assessing related advantages and challenges in rural Japanese communities, using a mixed-methods approach. Disability-free life expectancy from 65 years (DFLE-65) was assessed to compare healthy life expectancies between two rural Japanese cities (with/without multifunctional autonomy). Comparisons revealed better DFLE-65 only among older men in a city with multifunctional autonomy. A cost-effectiveness analysis investigated the relationship between the budget and DFLE-65 change using questionnaire data. Cost-effectiveness analysis of multifunctional autonomy indicated 61,147 yen/DFLE-65. Thematic analysis revealed that multifunctional autonomy created new roles for older men, improving community relationships. However, sustainable multifunctional autonomy in LSG communities may be hindered by a generally aging society, generation gap, and lack of mutual understanding between rural communities and local governments. To ensure the sustainability of multifunctional autonomy, collaborations between local communities and governments and among various generations are critical.

Strengths and Challenges for Medical Students and Residents in Rural Japan.

BACKGROUND AND OBJECTIVES: In Japan, family medicine training is driven by community-based medical education (CBME) and is often provided in rural community hospitals and clinics. Although CBME's positive relationship to family medicine in rural community hospitals is proven, the learning processes of medical students and residents in rural community hospitals needs investigating. The objective of this study was to reveal medical students' and residents' changing motivations and learning behaviors, as well as the factors underpinning their transition between medical schools or tertiary hospitals and rural community hospitals. METHODS: Over 2 years, the researchers conducted one-on-one interviews with 50 medical students and 30 residents participating in family medicine training at a rural community hospital, and analyzed the difficulties the participants encountered and how they overcame them. The interviews were audio recorded and transcribed verbatim. We used grounded theory in the data analysis to clarify the findings. RESULTS: Three key themes emerged: educational background, changing environment, and factors driving the learning cycle. Participants had difficulties in overcoming differences between their previous education and their CBME, particularly regarding expected roles and the variety of medical issues. They overcame their difficulties through cognitive apprenticeships and legitimate peripheral participation enhanced by daily reflection. CONCLUSIONS: In rural community hospitals, participants struggled to adapt to the wider practice range and the more interactive relationship with educators. Cognitive apprenticeships and legitimate peripheral participation, supported by constant reflection between learners and clinical teachers, can facilitate learning, leading to more effective learning and practice of family medicine in rural areas.

Realist evaluation of interprofessional education in primary care through transprofessional role play: what primary care professionals learn together.

Interprofessional collaboration (IPC) is vital to primary care. Improving IPC requires cooperation between medical and other healthcare professionals. Transprofessional role plays can enhance the quality of IPC; thus, in this study, we conducted transprofessional role plays, based on existing theories regarding IPC and medical education, with healthcare professionals in primary care. As a study design, the realist approach was used to clarify the effectiveness of transprofessional role plays. Five Likert-scale questionnaires regarding the competency of IPC were used to assess the change in perception of medical and care professionals through educational intervention. The realist approach was employed for the clarification of contexts, mechanisms and outcomes of transprofessional role play using one-on-one interview data. Sixty-two medical care professionals participated in the transprofessional role plays, and 31 participants were interviewed. The difference in the score of the competency scale of IPC was statistically significant in all six competencies (p-value <0.001). Three context, mechanism and outcome theories were clarified from the qualitative analysis of the interviews: reflection on others, realisation of own roles and driving humanistic relationship. Additionally, contextual factors, the mechanisms that facilitated them and the clarified outcomes were identified. Ultimately, in this realist evaluation transprofessional role plays proved to be effective in driving IPC in primary care through improving compassion and reliability across professions. The constant provision of the role play and mutual discussion of each professional's role can facilitate effective IPC in primary care.