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.

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.

Challenges Faced by Medical Trainees in Outpatient Management Education in Acute Care Hospitals: A Thematic Analysis.

Introduction As societies age globally, medical education faces the challenge of adapting to the evolving healthcare needs of an aging population. This study focuses on the education of medical residents in outpatient departments in Japan, a country with a rapidly aging society. The research aims to understand the perceptions and challenges medical residents face in outpatient management, highlighting the areas for potential improvement in their educational framework. Method This study involved first-year medical residents at Fuchu Hospital in Osaka, using thematic analysis based on relativist ontology and constructivist epistemology. Data were collected through field notes and reflection sheets, documenting residents' interactions with patients, learning difficulties, and personal reflections. Semi-structured interviews were conducted to gain profound insights into their experiences and views on outpatient management education. Results Three main themes emerged from the analysis: The experience of continuity of care, the view regarding comprehensive management, and the gap between purposes and learning content. Residents expressed concerns about the limited opportunities for continuous patient care, leading to challenges in managing chronic diseases effectively. The focus on organ-specific specialties in acute care hospitals resulted in a fragmented understanding of patient care, particularly for elderly patients with multimorbidity. Furthermore, the study identified a discrepancy between the educational goals of outpatient management and the actual content delivered, highlighting the need for more observational experiences and practical guidance in outpatient settings. Conclusion The findings suggest a pressing need for a more structured, comprehensive, and personalized approach to outpatient management education for medical residents. As aging populations continue to grow, it is vital to equip medical professionals with the skills and knowledge to manage a wide range of patient conditions effectively. Improving the educational framework in outpatient departments can enhance patient care quality and prepare medical residents to meet the challenges of an aging society. This study contributes valuable insights into improving medical education in outpatient settings, particularly in aging societies like Japan.

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.

Eosinophilic Granulomatosis With Polyangiitis Gradually Worsening With Consecutive Pregnancies: A Case Report.

This case report elucidates the diagnosis and management of eosinophilic granulomatosis with polyangiitis (EGPA), a form of systemic vasculitis, in a 32-year-old female presenting with progressive dermal, respiratory, and gastrointestinal symptoms following multiple pregnancies. The patient's history of allergic reactions and pregnancies suggested a gradual progression of EGPA, a condition rarely associated with pregnancy. Initial symptoms were misinterpreted as allergic reactions and acute gastroenteritis, delaying the correct diagnosis. Laboratory findings included eosinophilia and elevated immunoglobulin E, while further investigations ruled out other differential diagnoses, such as chronic eosinophilic leukemia. A clinical diagnosis of EGPA was made based on symptom progression, eosinophilia, and mononeuritis multiplex, absent typical granulomatous changes in the skin biopsy. Treatment with high-dose prednisolone and rituximab halted disease progression and improved symptoms, highlighting the critical importance of prompt diagnosis and treatment in preventing irreversible complications. This case emphasizes the need for general physicians to consider pregnancy as a potential trigger for autoimmune diseases like EGPA, especially in patients presenting with multi-symptom allergic reactions and high inflammatory markers.

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.

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.

Reconsidering the Role of Nurse Practitioners in Japan: What Direction Should Japanese Nurse Practitioners Aim for?

This article explores the dynamic role of nurse practitioners in Japan, contextualized against an aging population and declining birth rates. It emphasizes the imperative for Japanese nurse practitioners to broaden their scope of practice to effectively meet the nation's diverse healthcare demands within a constrained resource framework. The study highlights the critical need for Japan to align its nurse practitioners' training with international educational standards, advocating for a graduate-level curriculum that blends in-depth theoretical knowledge with practical skillsets. Central to the discourse is task shifting, wherein nurse practitioners progressively undertake duties traditionally associated with physicians. This expansion of roles requires meticulous evaluation to ensure its contribution to the efficacy of the healthcare system. The article identifies nurse practitioners as pivotal in team-based medical care, proficient in merging medical and nursing perspectives, and essential in facilitating communication and coordination among varied medical professionals. Comparative analysis of international nurse practitioner practice models reveals a necessity for Japan to enhance the scope and responsibilities of its nurse practitioners. Furthermore, the paper addresses the need for a comprehensive reevaluation of Japan's legal and policy framework concerning clinical nursing, aiming to redefine roles and responsibilities more distinctly. The article advocates for systemic reforms, particularly in education and multi-professional collaboration. These changes are deemed vital for Japanese nurse practitioners to respond to evolving healthcare needs effectively, ultimately elevating the standard of healthcare provision in Japan for a global audience.

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.

Atlantoaxial Subluxation as the Initial Presentation of Rheumatoid Arthritis: A Case Report.

Rheumatoid arthritis (RA) is known for its diverse manifestations, although atlantoaxial subluxation is a rare complication. This case report sheds light on the complexity of RA diagnosis, especially in the elderly, and emphasizes the significance of primary care in identifying atypical presentations. A 68-year-old male with a history of chronic obstructive pulmonary disease, hypertension, prior traumatic neck spinal injury, and lumbosacral stenosis presented to a rural community hospital with neck pain, bilateral numbness, and arm weakness. Initially diagnosed with degenerative cervical spondylosis, his condition later progressed to include swollen, painful wrists and metacarpophalangeal joints. Diagnostic tests revealed elevated rheumatoid factor and C-reactive protein, and hand X-ray showed bone erosions. An MRI confirmed an atlantoaxial subluxation. He was diagnosed with RA based on the American College of Rheumatology/European League Against Rheumatism 2010 criteria with a score of 7. The patient underwent cervical fusion surgery and rehabilitation, leading to significant functional improvement. This case underscores the importance of a comprehensive diagnostic approach in primary care for elderly patients presenting with non-specific symptoms. It highlights the need for heightened awareness among general practitioners of atypical RA manifestations, such as atlantoaxial subluxation. The case advocates for continued research into early detection and management strategies for such rare presentations to enhance patient outcomes in RA.

Relationship between Anemia and Readmission among Older Patients in Rural Community Hospitals: A Retrospective Cohort Study.

Readmission rates among older adults are a growing concern, and the association of readmission with anemia and the potential benefits of a systematic assessment and intervention remain unclear. This study investigated the association between anemia and readmission within 28 and 90 days in an older population. Data from 1280 patients admitted to the Department of General Medicine of Unnan City Hospital between April 2020 and December 2021 were retrospectively analyzed. Variables such as anemia status, Charlson comorbidity index (CCI) score, Functional Independence Measure (FIM) score, and dependent status were evaluated. Multivariate logistic regression was used to determine the associations between 28-day and 90-day readmissions. The average age was 84.9 years, and the prevalence of anemia was 36.4%. The readmission rates within 28 and 90 days were 10.4% and 19.1%, respectively. Anemia was significantly associated with readmission in both periods (28-day adjusted odds ratio, 2.28; 90-day adjusted odds ratio, 1.65). CCI score, FIM score, and dependent status were also identified as significant factors. Anemia is significantly associated with short- and medium-term readmissions in older patients. Addressing anemia, along with other identified factors, may help reduce readmission rates.

Addressing health challenges in rural Japan: a thematic analysis of social isolation and community solutions.

BACKGROUND: The establishment of sustainable connections between medical professionals and rural citizens is pivotal for effective community healthcare. Our study focuses on understanding and resolving health problems arising from social isolation, a critical barrier to achieving this goal, especially in the context of the coronavirus disease 2019(COVID-19) pandemic's impact on community dynamics respecting social cognitive theory. This study investigates the link between social isolation and rural community healthcare. We aim to develop methods that improve interaction and collaboration between healthcare providers and rural communities, ultimately enhancing the region's healthcare system. METHODS: Employing thematic analysis based on social cognitive theory, we conducted semi-structured interviews with 57 community workers in rural communities. This qualitative approach enabled us to delve into the nuances of social isolation and its multifaceted impact on health and community well-being. RESULTS: Our analysis revealed four key themes: the impact of aging on social dynamics, shifts in community relationships, unique aspects of rural community networking, and the role of these networks in driving community health. Notably, we identified specific challenges, such as the erosion of intergenerational interactions and the hesitancy to seek support, exacerbated by social isolation and negatively impacting community health. CONCLUSIONS: Our study reveals the complex factors affecting rural community sustainability, particularly social isolation influenced by privacy concerns and changing social dynamics. Emphasizing the importance of social cognitive theory, it highlights the need for adaptable healthcare systems and strong community-medical collaborations. Future research should focus on developing culturally sensitive, practical strategies for enhancing these collaborations, especially involving physicians, to address rural communities' unique challenges.

Enhancing Rural Health Dialogue: The Crucial Role of Reflective Practice in Family Physician Involvement.

Health dialogue plays a pivotal role in sustaining rural communities by enhancing help-seeking behaviors (HSBs). This article delves deep into how family physicians accentuate the efficacy of rural health dialogues, prompting rural citizens to evaluate and adapt their current HSBs critically. Establishing a foundation of trust in rural family physicians significantly influences the motivation for refined HSBs. Additionally, such engagements optimize the application of limited healthcare resources. For these outcomes to be realized, family physicians must amplify their communication and leadership abilities, and confront the inherent challenges of disseminating contemporary medical evidence in rural domains.

Primary Adrenal Insufficiency in Acute Progressive Systemic Inflammation Accompanied by Latent Tuberculosis: A Case Report.

A 64-year-old man presented with general malaise, edema, and other nonspecific symptoms, prompting extensive diagnostic evaluation. The patient's early morning cortisol and adrenocorticotropic hormone levels were consistent with primary adrenal insufficiency without evident secondary or tertiary causes on magnetic resonance imaging. The interferon gamma release assay (T-SPOT®) was positive, suggesting latent tuberculosis, although there were no signs of active tuberculosis. The potential of extrapulmonary tuberculosis as a causative factor for adrenal insufficiency was explored but remained unconfirmed on contrast-enhanced computed tomography. Eosinophilia was detected, suggesting a link between adrenal insufficiency and the occurrence of atopic dermatitis. This case underscores the multifaceted nature of adrenal insufficiency and its potential associations. While autoimmune conditions are commonly associated with adrenal insufficiency, infectious diseases (e.g., tuberculosis) can also be contributing factors. Eosinophilia further indicates the likelihood of coexisting allergic or atopic conditions, particularly adrenal dysfunction. Although not dominant, the presence of latent tuberculosis can cause severe complications, including adrenal insufficiency, highlighting the requirement of vigilant monitoring. Clinicians are advised to consider adrenal insufficiency in the differential diagnosis of patients with generalized symptoms and perform comprehensive evaluations, including cortisol level assessment and tuberculosis screening.

Acute Onset Rheumatoid Vasculitis With Polyarthritis and Erythema: A Case Report.

We present the case of a woman in her 70s who was diagnosed with rheumatoid vasculitis (RV) after initially presenting with systemic joint pain and erythema. RV, a rare complication of rheumatoid arthritis, involves inflammation of blood vessels, leading to various skin manifestations. The patient's complaints included fever, generalized joint pain, and skin manifestations that initially resembled erythema multiforme. However, a skin biopsy revealed vasculitis, which guided the RV diagnosis. Although rheumatoid arthritis primarily affects the joints, systemic implications such as RV can arise in rare cases. This case underscores the importance of a holistic and meticulous diagnostic approach, especially in older patients, as early detection and treatment are crucial for managing disease progression and associated complications. Collaborative care involving multidisciplinary teams is vital to achieving optimal outcomes in complex cases.

Diagnosis of Rheumatoid Vasculitis From Ischemic Change in Hands: A Case Report.

Rheumatoid arthritis (RA) is a chronic inflammatory disorder with a wide clinical heterogeneity. Among its complications, rheumatoid vasculitis (RV) is notable for its severity and potential to involve multiple organ systems. A particularly serious manifestation of RV is ischemia, which is indicative of advanced vasculitic involvement and a significant risk of tissue damage. This case report describes an 83-year-old male with RA who presented with polyarticular joint pain and hand ischemia. Despite the initial diagnosis of RA exacerbation, worsening systemic symptoms without identifiable infectious causes and hypocomplementemia led to the diagnosis of RV exacerbation. Initial management with steroids showed temporary improvement. However, relapse after dose reduction prompted the administration of rituximab, an anti-cluster-of-differentiate-20 (anti-CD20) monoclonal antibody, which yielded favorable outcomes. This case underscores the importance of clinical vigilance in older patients with RA for signs, such as ischemic hands, emphasizing the pivotal role of early detection and intervention in RV management, particularly in community hospital settings.

Salmonella Bacteremia in an Older Patient With No Specific Entry: A Case Report.

In this case report, we describe a rare case of non-typhoidal Salmonella bacteremia in an 87-year-old woman with no apparent history of daily Salmonella exposure. The patient presented with fever, body discomfort, and diarrhea. Medical examinations ruled out usual sources of Salmonella, including raw food consumption and pet contact. Her medical history included postoperative sigmoid colon cancer, left breast cancer, and other ailments. Although Salmonella infection typically stems from oral intake, this case suggests that bacterial translocation from the gastrointestinal tract could be the primary cause, potentially exacerbated by the patient's age and medical history. Another hypothesis is an ascending infection from diarrhea to the urinary tract, which might have led to pyelonephritis and subsequent bacteremia. This case highlights the importance of recognizing the potential for severe infections such as sepsis in older individuals presenting with diverse symptoms. Therefore, this case further underscores the need for heightened clinical vigilance, especially in community hospitals, to ensure timely and appropriate management of such severe conditions in the older population.