Surgical Interventions in Cases of Esophageal Hiatal Hernias among Older Japanese Adults: A Systematic Review

Deciding a Treatment Plan for an Older Patient With Severe Idiopathic Pulmonary Fibrosis: A Case Report

Idiopathic pulmonary fibrosis (IPF) is a group of diseases in which the main loci of lesions, mainly inflammatory and fibrotic, are within the interstitium of the alveolar and bronchiolar regions. Steroid therapy is the standard treatment for acute exacerbation of IPF, whereas antifibrotic agents are the standard treatment for chronic IPF. However, the vulnerability of older patients indicates that these treatments may be discontinued. Here, we report the case of an 86-year-old woman who had a dry cough for over a year and was subsequently diagnosed with IPF based on imaging studies. After using steroid pulses to treat acute exacerbations, the patient was transitioned to the chronic management phase, and time was allowed to plan the patient's advanced care with her family. The use of high-dose steroids in older patients with frailty is contraindicated. This case emphasizes the importance of considering initial intensive treatment for IPF in older patients for better palliative care.

Seronegative Rheumatoid Arthritis in an Elderly Patient With Anemia: A Case Report

Anemia due to chronic inflammation reduces the quality of life in the elderly population. Various causes of chronic inflammation exist, and the elderly experience varying symptoms, making it challenging to investigate the cause. The risk of chronic inflammatory diseases, including autoimmune diseases, and the risk of rheumatoid arthritis (RA) increase with age. Here, we report a case of seronegative RA in an 88-year-old woman who was referred for a detailed examination of chronic inflammation and anemia. Although she had no chief complaint, a physical examination revealed bilateral symmetric polyarthritis. After ruling out other diseases based on blood culture findings, the patient was diagnosed with seronegative RA. She was successfully treated with prednisolone and methotrexate, and her anemia improved. She also attributed the anemia to a chronic inflammatory pattern of seronegative RA. Appropriate physical examination is important for older adults with various complaints, and anemia may precede arthritis during the clinical course of RA. Additionally, inflammation may progress rapidly in these individuals.

Possible Macrophage Activation Syndrome Caused by Endoscopic Retrograde Cholangiopancreatography for Bacteremia Due to Chronic Cholelithiasis

Hypoglycemia is caused by various clinical diseases. Among older patients, occult bacteremia may cause critical illness-related corticosteroid insufficiency (CIRCI), triggering hypoglycemia. Additionally, older patients have various chronic medical and homeostatic conditions. Interventions may be needed when chronic conditions cause clinical diseases and CIRCI. Herein, we report a case of possible macrophage activation syndrome (MAS) caused by endoscopic retrograde cholangiopancreatography for bacteremia due to chronic cholelithiasis in an 85-year-old man. Interventions for chronic conditions could impinge on homeostasis in older patients, causing acute conditions such as MAS. Among older frail patients with chronic conditions, interventions for chronic conditions should be discussed, including the triggering of other acute conditions, such as MAS.

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.

Peripheral T-cell Lymphoma With Acute Exacerbating Fatigue and Chest Pain: A Case Report

Effectively treating vague symptoms in older adults can be challenging for clinicians. Many vague symptoms will resolve spontaneously with alleviating treatment. Two of the most alarming qualities of symptoms are duration and exacerbation. For primary care and family medicine physicians dealing with vague symptoms in older patients, identifying alarming symptoms and further investigating them can guide their decisions on advanced care directives. We experienced a case of a drastic clinical course of peripheral T-cell lymphoma in a 91-year-old man without specific symptoms or palpable lymphadenopathy on the surface of the body. Clinical observation and prompt pathological investigation were sufficient for diagnosis. However, the patient’s hope for home-based palliative care could not be achieved. For vague progressive symptoms in older patients, clinicians should consider the diagnostic process, including perspectives of palliative care, based on the needs of older patients.