Chiaki Sano

This systematic review synthesized findings from 17 studies conducted between 2000 and 2024, focusing on the definitions, interventions, and outcomes associated with community nursing. The studies originated from diverse countries, including Singapore, Australia, Italy, Portugal, and the United States, and employed various designs such as quasi-experimental trials, pre-post evaluations, and descriptive studies. Sample sizes ranged from 23 to over 1,600 participants, with most targeting older adults or individuals with chronic conditions. Definitions of community nursing varied, reflecting differences in national healthcare systems. Still, common features included nurse-led services focused on prevention, self-management support, and care coordination in non-hospital settings. Interventions ranged from short-term health fairs to long-term, structured programs, often including health assessments, lifestyle coaching, medication adherence support, and caregiver education. Outcomes were grouped into four categories: healthcare service utilization, patient-reported outcomes, clinical indicators, and quality of life. Notably, one large-scale program in Singapore reported a 23% reduction in emergency department visits. Other studies documented increases in self-monitoring behavior, improved self-efficacy, and greater patient satisfaction. However, limitations included small sample sizes, non-randomized designs, and reliance on self-reported data. Despite these constraints, the review highlights the potential of community nursing to improve individual health outcomes and reduce healthcare system burdens.

Thromboembolic events related to coagulopathy have been frequently reported in patients with coronavirus disease 2019 (COVID-19), with elevated D-dimer levels being a significant risk factor for these events. While arterial thrombosis is less common than venous thrombosis, there are reports of myocardial infarction, ischemic stroke, and acute limb ischemia. Complete abdominal aortic occlusion, however, is exceptionally rare. We present a rare case of a 94-year-old male who developed complete abdominal aortic occlusion on day four of COVID-19 illness, despite early initiation of prophylactic anticoagulation along with standard antiviral and steroid therapy. The patient presented with a markedly elevated D-dimer level. After the sudden onset of severe pain from the back to the lower limbs, paralysis, and coldness of both legs, contrast-enhanced CT revealed thrombotic occlusion extending from the abdominal aorta to both iliac arteries. This case suggests that COVID-19-associated coagulopathy may progress to a severe state unmanageable by anticoagulation alone and underscores the importance of rapid evaluation and intervention for arterial thrombosis, including abdominal aortic occlusion, when acute limb ischemia-like symptoms occur.

The coexistence of small-cell lung cancer (SCLC) and primary gastrointestinal (GI) malignancies is an exceptionally rare phenomenon that complicates diagnosis and treatment. We conducted a systematic review of published case reports to better understand the clinical characteristics, therapeutic approaches, and outcomes of these patients. A comprehensive search of major databases up to April 2025 identified six eligible reports describing patients diagnosed with both SCLC and distinct GI cancers, including gastric, duodenal, rectal, and jejunal tumors, as well as one patient with multiple primary malignancies involving rectosigmoid adenocarcinoma, renal cell carcinoma, and prostate adenocarcinoma in addition to SCLC. The patients were predominantly older males with heavy smoking histories, and most cases were extensive-stage SCLC at presentation. Treatment varied widely and included platinum-based chemotherapy, immune checkpoint inhibitors, EGFR-targeted therapy, surgery, and supportive care, with clinical outcomes ranging from a few months to more than one year of survival. Several patients showed partial or complete responses to systemic therapy, and in one case, the GI malignancy regressed following chemotherapy given for SCLC, suggesting overlapping chemosensitivity. However, other patients experienced delayed diagnosis of the second malignancy or limited survival due to disease progression or comorbidities. This synthesis demonstrates that distinguishing dual primaries from metastatic disease is a critical challenge in clinical practice and highlights the need for thorough evaluation in patients with atypical or persistent symptoms. Although data remain limited, awareness of this rare coexistence may help clinicians avoid misclassification and tailor multidisciplinary treatment strategies to improve outcomes.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is an uncommon inflammatory disorder that may occur as a paraneoplastic manifestation. To clarify its clinical profile, we reviewed published cases and observational studies reporting paraneoplastic RS3PE. A total of 120 patients were identified, including 40 individual case reports and four observational cohorts. The mean age was 69 years, and men accounted for approximately 70-80% of patients. Associated malignancies were diverse, with prostate (22%), lung (18%), and gastrointestinal cancers (16%) being the most frequent among solid tumors, alongside hematologic malignancies such as lymphoma and leukemia (12%). The hallmark clinical presentation was symmetrical synovitis of the hands and feet with pitting edema. Systemic features were common, including fever (36%), weight loss (28%), and fatigue (21%). Corticosteroid responsiveness varied: pooled analysis demonstrated an overall response rate of 78.4%, but outcomes differed by region. For example, two Japanese and U.S. cohorts reported remission in over 85% of patients, whereas a Chinese cohort described only 42.8% achieving remission. Relapses were frequent and often paralleled cancer progression, reinforcing the link between RS3PE activity and malignancy status. In 59.5% of cases, RS3PE was diagnosed simultaneously with cancer, while in others it preceded (25%) or followed (15%) cancer diagnosis. These findings suggest that paraneoplastic RS3PE is a distinct clinical entity and a sentinel marker of malignancy. Comprehensive cancer screening should be prioritized in affected patients, particularly older men with systemic symptoms or inadequate steroid response. Further multicenter research is needed to establish biomarkers and optimize management strategies.

Hypervirulent Klebsiella pneumoniae (hvKp) is an emerging cause of pyogenic liver abscess (PLA), characterized by virulence genes, such as rmpA and rmpA2, as well as capsular types K1/K2 that enhance mucoviscosity and invasiveness. Although regionally predominant in East Asia, cases are increasingly reported worldwide. We reviewed case reports and case series published between 2000 and 2025 describing hvKp-related PLA with individual-level data. Clinical, microbiological, and outcome variables were summarized descriptively due to heterogeneity across reports. Fifty-three patients from 34 studies were included, mainly from Japan, South Korea, and China. The mean age was 66.2 years, and 81% were male. Diabetes mellitus was the most frequent comorbidity (57%). Reported virulence factors included rmpA (43%), magA (25%), and K1 (43%) or K2 (19%) serotypes. Metastatic infection occurred in 36% of cases, most commonly endophthalmitis (36%), followed by pulmonary (19%) and central nervous system involvement (15%). No carbapenemase-producing strains were identified; most isolates remained broadly susceptible. Third-generation cephalosporins (53%) and carbapenems (26%) were the main therapies, often combined with percutaneous drainage (45%). Overall mortality was 6%, and 23% experienced permanent vision loss. hvKp liver abscess generally carries a low mortality but a high risk of disabling metastatic complications. Early ophthalmologic evaluation and vigilant surveillance for dissemination are essential, and recognition of virulence markers distinguishes hvKp PLA from multidrug-resistant Klebsiella pneumoniae infections.

BackgroundPneumococcal pneumonia remains a leading cause of morbidity and mortality among older adults, particularly in rural areas with limited healthcare access. Despite national recommendations, vaccination uptake in rural Japan remains suboptimal. Evidence suggests that patient education, reminder systems, and streamlined workflows can enhance preventive care in outpatient settings. This quality improvement (QI) project aimed to increase pneumococcal vaccination rates by at least 20% within three months among older patients in a rural Japanese hospital.MethodsThe project was conducted at Unnan City Hospital, a rural healthcare facility with a high proportion of older adults, from February to April 2025. Using the Plan-Do-Study-Act (PDSA) framework, three low-cost interventions were implemented: (1) patient and staff educational brochures; (2) electronic medical record (EMR)-based reminders; and (3) a standardized vaccination flowsheet. Eligible patients were aged ≥65 years with chronic conditions who regularly attended outpatient visits. Outcome measures included weekly vaccination rates; process measures included recommendation and reminder rates; and balance measures included staff satisfaction and perceived workload. We used run charts and interrupted time-series analysis (ITSA) to assess temporal changes; this method allows for the analysis of trends over time but has a limited ability to determine causality.ResultsBaseline vaccination coverage averaged 17.4% over eight months prior to the intervention. Following the QI project, vaccination rates increased to 65.0% within three months. ITSA demonstrated a significant post-intervention increase of 3.97 percentage points per week (p < 0.001). Physician recommendation rates improved from 24% to 83%, and reminder rates consistently exceeded 91%. Staff satisfaction with workflow and team communication improved, while perceived workload remained manageable. Qualitative feedback informed iterative adjustments, including daily vaccination limits and enhanced communication.ConclusionsThis multicomponent intervention was associated with substantial increases in pneumococcal vaccination rates among older adults in a rural hospital. Integrating EMR-based reminders, patient education, and interprofessional collaboration into routine practice proved feasible and scalable. This model may serve as a practical framework for enhancing adult vaccination in similar rural healthcare settings.

Although physical activity is known to improve outcomes in non-metastatic colorectal cancer (CRC), its effect on metastatic colorectal cancer (mCRC) remains unclear. This study systematically reviewed and meta-analyzed the association between exercise and overall survival (OS) among patients with mCRC. A comprehensive search of PubMed, Embase, and Web of Science was conducted for studies published from 2000 to September 2025. Eligible studies evaluated exercise or physical activity in adults with histologically confirmed mCRC and reported survival outcomes. Hazard ratios (HRs) for OS were pooled using a random-effects model. Study quality was assessed using the Newcastle-Ottawa Scale (NOS), and heterogeneity was evaluated with the I² statistic. Four prospective cohort studies comprising 2020 patients met the inclusion criteria. Exercise types were predominantly mild to moderate aerobic activities such as walking or light household chores. The pooled HR for OS was 0.64 (95% CI, 0.48-0.87), indicating a 36% reduction in mortality among physically active patients compared with those who were inactive. Heterogeneity was substantial (I²=74.5%), but the direction of effect was consistent across studies. All studies were of moderate to high quality (NOS 7-8). Funnel plot analysis showed mild asymmetry, suggesting possible publication bias. Mild to moderate physical activity is significantly associated with improved OS in patients with mCRC. Even low-intensity activities such as walking may offer survival benefits and are feasible for patients with advanced disease. These findings support the incorporation of moderate exercise into multidisciplinary care for mCRC, although the observational nature of the available studies limits the ability to draw causal inferences. Large-scale prospective trials are warranted to determine optimal exercise regimens in this population.

Streptococcus dysgalactiae subsp. equisimilis (SDSE) has been increasingly recognized as a causative pathogen of skin and soft tissue infections and bacteremia, particularly in elderly individuals or those with underlying comorbidities. It typically presents with fever and localized pain associated with cellulitis; however, it may occasionally manifest with nonspecific symptoms, leading to diagnostic delay.We report the case of an 87-year-old man who presented with abdominal and lower back pain, initially suspected to have intestinal ischemia based on contrast-enhanced computed tomography findings and elevated serum lactate levels, but was later diagnosed with SDSE bacteremia following positive blood cultures and subsequent identification of cellulitis between the right third and fourth toes.After initiation of antimicrobial therapy with ampicillin/sulbactam and intravenous fluids, his fever and inflammatory response improved. Based on the clinical course, it was suggested that bacteremia-related circulatory disturbances and transient intestinal ischemia might have contributed to the nonspecific abdominal and back pain.This case highlights the importance of recognizing SDSE bacteremia as a potential etiology of atypical initial symptoms - such as abdominal or back pain - even before the development of overt skin lesions.

Rathke’s cleft cyst (RCC) is a benign pituitary lesion that is often asymptomatic but can cause hypopituitarism, including central adrenal insufficiency, which may become clinically apparent under physiological stress. However, RCC presenting with adrenal insufficiency unmasked by acute respiratory illness is rare, particularly in elderly patients. We report a case of RCC diagnosed after adrenal insufficiency became evident following pneumonia-associated asthma exacerbation. An 89-year-old woman presented with fever, productive cough, and generalized fatigue and was diagnosed with pneumonia-triggered asthma exacerbation. Initial laboratory evaluation revealed hyponatremia (serum sodium 126 mEq/L). She was treated with bronchodilators, systemic corticosteroids, and antibiotics, resulting in prompt improvement of respiratory symptoms and normalization of serum sodium levels. After discontinuation of corticosteroids and discharge, she developed persistent fatigue, anorexia, and right eyelid ptosis. Brain magnetic resonance imaging revealed a 22-mm cystic lesion in the pituitary gland consistent with RCC. Endocrine evaluation demonstrated markedly reduced adrenocorticotropic hormone and cortisol levels, along with central hypothyroidism, hypogonadism, and growth hormone deficiency, confirming panhypopituitarism with central adrenal insufficiency. Hydrocortisone replacement therapy was initiated, leading to clinical stabilization. Surgical intervention was deferred due to advanced age and absence of visual field defects, and the patient was managed conservatively with hormone replacement and follow-up imaging. This case highlights that acute respiratory illness may precipitate overt adrenal insufficiency in patients with previously unrecognized RCC. Transient improvement with corticosteroids during acute treatment may mask the underlying endocrine disorder, delaying diagnosis. Persistent fatigue, hyponatremia, or neurological findings after resolution of respiratory illness should prompt evaluation for central adrenal insufficiency and pituitary pathology, as early recognition and hormone replacement are essential to prevent life-threatening complications.

Liver abscess is a severe infection that can progress to septic shock. Although early fluid resuscitation is recommended in septic shock, patients with heart failure, particularly those with heart failure with preserved ejection fraction (HFpEF), are prone to fluid overload, making volume management challenging. In addition, hemodynamic instability may occur even after source control. We report the case of a 91-year-old man with a history of HFpEF who was transported to our hospital with fever and difficulty ambulating. He was diagnosed with septic shock secondary to a liver abscess caused by Escherichia coli. Initial resuscitation was performed with antibiotics, vasopressors, and approximately 6.5 L of intravenous fluid, followed by percutaneous drainage. Although his hemodynamic status temporarily improved, shock recurred after the drainage procedure. During hospitalization, he experienced multiple episodes of heart failure exacerbation associated with fluid shifts, requiring careful fluid management, including diuretics and respiratory support. His general condition subsequently improved, and he was successfully weaned from intensive care. This case suggests the importance of balancing adequate initial resuscitation with avoidance of fluid overload in septic shock complicated by HFpEF, and the potential for transient hemodynamic deterioration following source control. Individualized fluid management and close periprocedural monitoring are essential in such patients.