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

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.

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.

Rural health dialogue for the sustainability of help-seeking behaviors among older patients: grounded theory approach

BACKGROUND

Help-seeking behaviors (HSBs) are essential for disease prevention and health promotion. Dialogues with peers and medical professionals can improve HSBs, both qualitatively and quantitatively. Rural communities lacking healthcare resources require effective HSBs for healthcare sustainability. The current study aimed to investigate the effect of health dialogues between medical professionals and rural citizens on their HSBs.

METHODS

All procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20,220,002). A grounded theory approach was employed for the health dialogue participants in rural communities. Health dialogues with family physicians were conducted once a month at rural community centers. The dialogues and focus group interviews were recorded and coded to investigate changes in participants' perceptions and behaviors regarding HSBs.

RESULTS

Twenty-one dialogues were conducted in two rural community centers, with a total of 112 participants. The average age of the participants was 70.2 years (standard deviation = 5.4), with 24% being males. Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue driving the realization of HSBs, reflection on personal HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, hence motivating safe and secure HSBs.

CONCLUSIONS

Mitigation of barriers between citizens and medical professionals and improvement of psychological safety in communities can drive effective HSBs in rural communities.

Difficulty in Diagnosing Anti-neutrophil Cytoplasmic Antibody-Related Vasculitis With Interstitial Pneumonia and in Ascertaining the Cause of Associated Hematochezia: A Case Report

The diagnosis of rheumatological diseases is challenging among older patients with multimorbidity. Rheumatological diseases in older patients show varied symptoms, such as fatigue, fever, and appetite loss. We encountered an older woman with anti-neutrophil cytoplasmic antibody (ANCA)-related vasculitis complicated by cytomegalovirus (CMV) infection. The case was further complicated by hematochezia and was eventually diagnosed as CMV infection with adverse reactions to medications. This case highlights the difficulty of diagnosing ANCA-related vasculitis and dealing with the complications arising due to the side effects of therapy.

Challenges in Help-Seeking Behaviors among Rural Older People Mitigated through Family Physician-Driven Outreach: A Systematic Review

Help-seeking behaviors (HSBs) refer to approaches taken by individuals towards their health and symptoms, and they are supported by healthcare professionals. Outreach interventions aimed at older people in rural communities can mitigate difficulties in implementing HSBs and help them remain healthy. This systematic review investigated evidence regarding family medicine-involved outreach aimed at HSBs among older individuals in rural areas. We searched three databases (PubMed, EMBASE, and Web of Science) for international and original interventional articles regarding family physicians involved in outreach to older people in rural or underserved areas between April 2000 and October 2022. The articles were analyzed and summarized based on the setting, country, health issues, and outreach outcomes. Of the 376 studies identified, four were included in this review. Our findings showed that family physician-involved outreach to rural and underserved areas improved health outcomes, including anxiety, subjective physical function, and diabetic care. The challenges of outreach interventions include the duration and continuity of outreach, the active participation of family physicians and patients in the outreach programs, and the focus of outreach participants. Although the number of studies included was small, family physician-involved outreach to rural and underserved areas was shown to improve various health outcomes.

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

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

Refractory Immunoglobulin A (IgA) Vasculitis in an Elderly Patient: A Case Report

Immunoglobulin A (IgA) vasculitis is small-vessel arteritis triggered by autoimmunity and allergies. IgA vasculitis among elderly patients is rare, and there is a lack of evidence regarding the choice of medicine and treatment duration. The main treatment for IgA vasculitis is steroids which can be cured with a small dose of prednisolone without immunosuppressants. Here, we report a case of a 90-year-old patient with the chief complaint of appetite loss and purpura on the legs who was diagnosed with IgA vasculitis based on biopsy results. The patient was initially treated with prednisolone effectively but exacerbated with steroid tapering, eventually requiring the use of an immunosuppressant. This case highlights the importance of monitoring the symptoms of IgA vasculitis while tapering steroids and clarifying the timing of immunosuppressant initiation.

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

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

Relationship between Dysphagia and Home Discharge among Older Patients Receiving Hospital Rehabilitation in Rural Japan: A Retrospective Cohort Study

Dysphagia refers to swallowing difficulty, which impacts patients' quality of life. Dysphagia influences clinical outcomes, including mortality rates and length of hospital stay of older hospitalized patients. Dysphagia may affect the current and future quality of life of these patients. However, its exact impact remains unclear. We aimed to clarify the impact of dysphagia on discharge to home in older patients in a rural rehabilitation unit. We conducted a secondary analysis using data from a retrospective cohort study including patients aged over 65 years who had been discharged from a community hospital rehabilitation unit in rural Japan. Data from the participants had been previously collected from April 2016 to March 2020. The primary outcome was home discharge. The average participant age was 82.1 (standard deviation, 10.8) years; 34.5% were men. Among medical conditions, brain stroke (44.3%) was the most frequent reason for admission; the most frequent orthopedic condition was femoral fracture (42.9%). The presence of dysphagia (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.20-0.73), polypharmacy (OR = 0.5, 95% CI: 0.32-0.90), and admission for internal medicine diseases (OR = 0.44, 95% CI: 0.26-0.77) were negatively associated with home discharge. High motor domain scores of the Functional Independence Measure were positively associated with home discharge (OR = 1.07, 95% CI: 1.05-1.08). Dysphagia was negatively associated with home discharge as were polypharmacy and admission for internal medicine diseases and conditions. By clarifying effective interventions through interventional studies, including approaches to managing multimorbidity and polypharmacy through interprofessional collaboration, the health conditions of older patients in rural areas may be improved.

Localized Pancreatitis in an Elderly Patient Without Suspected Etiology

Once pancreatic inflammation is triggered, it spreads throughout the pancreas. Here, we present a case of localized pancreatitis wherein the inflammation was confined to the pancreatic head. A 91-year-old woman was admitted with complaints of vomiting and epigastric pain. Blood tests showed elevated pancreatic enzyme levels, whereas imaging studies showed an enlarged pancreatic head and an area of increased density in the surrounding fatty tissue extending along the retroperitoneum below the subrenal pole. Atrophy of the pancreatic parenchyma in the pancreatic body and tail and dilatation of the main pancreatic duct were observed. The patient was diagnosed with acute pancreatitis, was kept nil by mouth, and was administered supplemental fluids. The symptoms resolved within two weeks. Age-related anatomical and histological changes in the pancreas may influence the development of pancreatitis, making it difficult to rule out the possibility of cancer. As age-related changes in the pancreas could lead to the development of pancreatitis, it is an important differential diagnosis of abdominal pain, even in older patients without suspected etiologies.

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

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

Hashimoto Encephalopathy of a Middle-Aged Man With Progressive Symptoms of Dementia

Autoimmune encephalitis is caused by immunological reactions showing unconsciousness, agitation, and other neurological symptoms. Autoimmune diseases can be related to autoantibodies, causing encephalitis. These autoantibody-related encephalitides could appear in various clinical courses. As laboratory tests for detecting these antibodies are limited, diagnosis is difficult. Hashimoto’s encephalopathy is autoimmune encephalitis caused by antibodies against the thyroid gland. This time, we experienced a case of a 69-year-old man with a chief complaint of subacute progression of amnesia and suspected autoimmune encephalitis, who was finally diagnosed with Hashimoto’s encephalopathy in a rural community hospital. In this case, clinicians should consider Hashimoto's encephalopathy as a differential diagnosis and measure antithyroid antibodies when acute or subacute onset cognitive impairment is observed in middle-aged patients. As a super-aging society significantly affects community hospitals, general physicians need to start treatments for encephalopathy and encephalitis when clinicians suspect the disease and rule out other critical diseases.

Coexistence of Pancytopenia and Myositis After Developing COVID-19

COVID-19 causes not only acute but also subacute medical conditions during the clinical course. COVID-19 causes severe inflammatory conditions; therefore, patients may develop long-term complications. Among patients with acute COVID-19, some patients can experience persistent symptoms, such as fatigue, joint pain, and smell and taste abnormalities, known as the long COVID-19 syndrome. The symptoms can be severe and require continuous medical care. Patients with severe clinical courses of COVID-19 may have critical symptoms again after the cure of the acute infections, especially among older patients. We encountered a case of neutropenia and myositis one month after contracting COVID-19. An 89-year-old man presented to our hospital with acute-onset systemic muscle pain and difficulty in movement and speaking. The patient had neutropenia and myositis with an extremely high level of immunoglobulin G caused by COVID-19. A granulocyte colony-stimulating factor could be effective for treating neutropenia. Besides, prednisolone was effective for treating myositis. In community hospitals, after developing COVID-19, appropriate history taking and physical examination should be performed in older patients with ambiguous symptoms, as they might have critical medical conditions such as neutropenia and myositis. The appropriate diagnosis and treatments of older patients with the complications of COVID-19 should be performed.

Students’ Learning on Sustainable Development Goals through Interactive Lectures and Fieldwork in Rural Communities: Grounded Theory Approach

Sustainable social-resource-based community management and sustainable development goals (SDGs) are crucial for community sustainability and sustainable development, respectively, and SDG education is vital to motivate people to continue SDG-appropriate activities. This study aims to evaluate the effectiveness of the SDG education of Rural Japanese University students using the grounded theory approach and investigate how their ideas about future work subsequently change. This study analyzes the learning and attitude changes in students enrolled in an elective SDG course and establishes the learning theory behind SDG education in rural universities. In this approach, student SDG education consists of three themes and eleven concepts. Through SDG education based on interactive lectures and rural fieldwork, participants reconsider community and society concepts in an SDG-minded framework. Based on this new perspective, participants begin considering community sustainability by gaining new insight from a first-person standpoint. Participants acquire SDG-minded working competencies, such as collaborative advancement, respect for inclusive societies, community revitalization from different perspectives, and mindset reconstruction. SDG educational processes were conducted in rural communities through university student SDG education, which deepened their understanding of community sustainability. Thus, SDG education should employ real practitioners to university curricula and deal with cultural and traditional diversity via effective collaboration.

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

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

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.

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.

Hemodialysis-Related Pericarditis With Cardiac Tamponade

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

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.

A Rare Case of Herpes Esophagitis in an Immunocompetent Elderly Patient

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

Difficulty in Diagnosing and Treating a Prostate Abscess With Bacterial and Fungal Coinfection in an Immunocompromised Patient

Prostate abscesses often occur in immunocompromised individuals. Contrast-enhanced imaging tests can aid diagnosis; however, they can be difficult to perform in older patients with renal insufficiency. Various organisms can cause prostate abscesses, and poor antibiotic penetration into the prostate can hinder treatment. Here, we report a case of prostate abscess manifesting as fever of unknown origin. The patient, a 78-year-old man with a history of heart failure, renal failure, and liver cirrhosis, presented with dyspnea and fever. He was initially diagnosed with aspiration pneumonia. However, the fever persisted, and urinary tract infection was diagnosed and treated with antibiotics and antifungal drugs. Further investigation with contrast-enhanced computed tomography revealed a prostate abscess. This case demonstrates the importance of aggressive investigation of fever of unknown origin in older patients with renal insufficiency. Furthermore, the problem of tissue penetration of antimicrobial agents should be thoroughly considered when treating prostate abscesses.

Fatal Bleeding From a Common Iliac Arterio-Ureteral Fistula in an Older Patient

Fatal ureteral bleeding is rare among elderly individuals. One cause of bleeding can be a fistula between the arteries and urinary organs, such as a common iliac arterio-ureteral fistula. However, the clinical presentation of fistulas can vary. As microscopic hematuria can be an initial finding, detecting the fistula without gross hematuria may be difficult. Here, we report a case of microhematuria that progressed to massive hematuria caused by a common iliac arterio-ureteral fistula. The patient was an 86-year-old man with a chief complaint of cardiopulmonary arrest. He was resuscitated in the previous condition. He had microscopic hematuria. One month later, the patient underwent rehabilitation. He was in hemorrhagic shock with massive hematuria. Further investigation revealed a right common iliac arterio-ureteral fistula. This case demonstrates the importance of investigating anemia in the elderly, including anemia of urinary origin, despite it being rare.

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.

Pericarditis With Cardiac Tamponade Mimicking Yellow Nail Syndrome in a Patient With Rheumatoid Arthritis and a Paucity of Joint Symptoms

Pericarditis is a cardiac disease that commonly manifests with rheumatoid arthritis, and its complications are related to rheumatoid arthritis disease activity. The diagnosis can be complicated in patients with multiple extra-joint complications of rheumatoid arthritis. We report a case of pericarditis in an 82-year-old woman with few joint symptoms who was admitted to the hospital due to worsening edema of the lower legs and dyspnea, which progressed to cardiac tamponade. The patient presented with gradual onset of edema of both lower limbs and bilateral pleural effusion and was initially diagnosed with yellow nail syndrome. Ultimately, the patient was diagnosed with rheumatoid pericarditis due to a rapid increase in pericardial effusion. She was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine; however, the symptoms were progressive and required pericardiocentesis. After pericardiocentesis, the patient responded well to NSAIDs and colchicine, and systemic edema was relieved. This case highlights the fact that pericarditis associated with rheumatoid arthritis is not necessarily related to the severity of joint symptoms. Moreover, it can be difficult to differentiate pericarditis from multiple other diseases, such as yellow nail syndrome, in patients with rheumatoid arthritis who mainly have extra-articular symptoms.

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.

Potential Help-Seeking Behaviors Associated with Better Self-Rated Health among Rural Older Patients: A Cross-Sectional Study

Help-seeking behaviors (HSB) for mild symptoms vary because of differences in health care resources and patients' backgrounds. Potential HSBs for lay and professional care use are related to patients' health conditions. However, there is a lack of evidence of the relation between them. This study examined the relation between patients' potential HSBs and self-rated health (SRH). The cross-sectional study involved 169 patients, aged above 65 years, who visited a Japanese rural clinic. A validated checklist was used to assess potential patients' HSBs. A chi-square test and logistic regression were performed to examine the relation between patients' self-rated health and HSB regarding lay and professional care use. Participants were 77.5 years old, on average (SD = 8.3). Results reveal that having regular exercise habits (OR = 2.42, p = 0.04), adequate sleep (OR = 4.35, p = 0.006), work (OR = 2.59, p = 0.03), high socioeconomic status (OR = 6.67, p = 0.001), and using both lay and professional care (OR = 2.39, p = 0.046) were significantly correlated with high self-rated health. Living alone was negatively correlated with higher SRH (OR = 0.23, p = 0.015). To improve rural patients' health care, in addition to improving their health management skills, potential HSB for mild symptoms should be investigated and interventions that consider patients' socioeconomic factors and living conditions should be implemented.

The Association between the Self-Management of Mild Symptoms and Quality of Life of Elderly Populations in Rural Communities: A Cross-Sectional Study

Maintaining people’s health based on their help-seeking behavior (HSB) regarding mild symptoms is essential. An effective HSB, especially self-management, can facilitate the attainment of appropriate healthcare resources and affect health outcomes such as quality of life (QOL). However, clear evidence regarding the relationship between self-management, mild symptoms, and QOL is unavailable. Therefore, this cross-sectional study investigated this association in a rural elderly population. The participants, aged over 65 years, were living in rural communities. The primary outcome of QOL was examined using the EuroQol 5-Dimension 5-Level (EQ-5D-5L). After adjusting for propensity score matching, 298 participants in the self-management usage group were matched with 298 in the group not using self-management. The most frequent HSB trend was consulting with primary care physicians, followed by self-care, consulting with families, utilizing home medicines, and buying medicines. The EQ-5D-5L scores were statistically higher in the self-management usage group than in the other group. The HSBs with a trend of using self-management were related to a high QOL. Self-management of symptoms along with other HSBs can improve elderly HSBs in rural contexts. Educational interventions and system development for HSBs in rural contexts could be effective in enhancing the QOL of rural elderly populations.