Ryuichi Ohta

IntroductionJapan’s Regional Quota System (ChiikiWaku) was established to address physician shortages in rural areas by supporting medical students with scholarships in exchange for service commitments. However, the specialty choices of quota students sometimes diverge from the regional healthcare needs. This study explored how specialty preferences change during medical education among regional quota students at the University of the Ryukyus in the Okinawa Prefecture, a region facing persistent healthcare disparities.MethodsA qualitative study using semi-structured interviews was conducted with regional quota students across different academic years at the University of the Ryukyus. Semi-structured interviews were selected for their flexibility and ability to capture in-depth experiences. Participants were purposively sampled to capture diverse perspectives. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically by a multidisciplinary research team, including quota and non-quota students, to enhance reflexivity and credibility.ResultsThematic analysis identified four central themes: (1) developing interests in various specialties through studying medicine, (2) hope and anxiety toward diverse futures, (3) dilemma between specialty limitations and the desire for career diversity, and (4) ambivalence toward general practice and its professional identity. The students' specialty preferences evolved through educational exposure, personal experiences, and negotiation between aspirations and systemic obligations. General practice was seen with both appreciation and uncertainty, reflecting the complex interplay between personal and policy-driven career trajectories.ConclusionRegional quota students’ specialty choices are dynamic and influenced by multiple factors during their medical education. Tailored support, including mentorship and early exposure to community-relevant specialties, may help better align the evolving aspirations of the students with the healthcare needs of underserved regions.

Thrombocytopenia is a frequent and clinically significant hematologic manifestation of systemic lupus erythematosus (SLE). A subset of patients develops refractory immune thrombocytopenia (ITP) despite standard therapy, creating a major therapeutic challenge. Targeted agents, including rituximab, belimumab, and thrombopoietin receptor agonists (TPO-RAs), have been used in small studies, but their overall effectiveness in SLE-associated refractory ITP has not been comprehensively evaluated. To systematically review and synthesize evidence on the effectiveness of rituximab, belimumab, and TPO-RAs for refractory ITP in adults with SLE, we conducted a systematic review and meta-analysis of observational studies following a prespecified protocol. Eligible studies included adults with confirmed SLE and refractory ITP treated with rituximab, belimumab, or TPO-RAs. Data were extracted on clinical outcomes, including complete response, partial response, and overall response rate (ORR). A meta-analysis of proportions using fixed-effects models was performed for each treatment category. Methodological quality was assessed using the Newcastle-Ottawa Scale. Eleven studies involving 11 cohorts met the inclusion criteria. Six cohorts (192 patients; pooled ORR 88.5% [170/192]) evaluated rituximab, two cohorts (14 patients; pooled ORR 92.9% [13/14]) evaluated belimumab, and three cohorts (31 patients; pooled ORR 96.8% [30/31]) evaluated TPO-RAs. Rituximab demonstrated a consistently high ORR of 88.5% (170/192) across studies. Belimumab showed an ORR of 92.9% (13/14), although small sample sizes limited evidence. TPO-RAs demonstrated the highest ORR of 96.8% (30/31), with rapid platelet recovery in most patients. Overall study quality was moderate, with larger rituximab cohorts providing the most substantial evidence, whereas belimumab and TPO-RA data were derived from small retrospective studies. Definitions of treatment response varied across studies. Rituximab, belimumab, and TPO-RAs appear to be effective therapeutic options for refractory SLE-associated ITP, with consistently high response rates across available studies. Evidence is strongest for rituximab, while belimumab and TPO-RAs show promising results that require confirmation in larger, well-designed prospective studies. Standardization of response criteria and improved safety reporting are needed to optimize treatment strategies for this challenging clinical condition.

Rural regions in Japan continue to experience significant health inequities despite universal health insurance coverage. These disparities disproportionately affect older adults, foreign residents, and socially isolated individuals, whose help-seeking is often delayed by structural, cultural, and informational barriers. This narrative review synthesizes empirical research, theoretical perspectives, and practice-based insights to clarify how social injustice manifests in rural Japanese healthcare and to identify strategies for more equitable care. Literature on rural health, health literacy, self-medication, mobility, and community participation was examined and interpreted through the frameworks of redistribution, recognition, and representation, as well as the capability approach. Across studies, persistent geographical barriers, transport limitations, and shortages of healthcare professionals restricted residents’ access to timely and appropriate care. Low health literacy, cultural differences, and weak social networks further hindered early help-seeking, particularly among foreign residents and older adults. Opportunities for participation in health decision-making were limited, reinforcing patterns of marginalization. Emerging community-based innovations-including non-profit-hospital collaborations, structured community dialogues, and digital consultation platforms-show potential to redistribute information, enhance cultural understanding, and strengthen residents’ capabilities to engage with the healthcare system. These findings suggest that achieving social justice in rural healthcare requires both structural reforms and capability-enhancing interventions that support meaningful participation by marginalized groups. Enhancing transportation, interpreter availability, community health worker programs, and co-designed communication pathways may contribute to a more inclusive and responsive rural healthcare system. This review provides a conceptual foundation for developing multilevel strategies to reduce inequities and promote social justice in rural Japan.

Rural communities often face structural and psychological barriers to healthcare access, particularly among older and socially isolated populations. Conventional clinic-based services may not adequately address early, ambiguous health concerns or facilitate low-threshold help-seeking. This technical report describes the implementation of a hybrid digital-physical health dialogue model designed to enhance accessibility, trust, and sustained engagement in a rural Japanese community. The intervention integrated an anonymous, free health consultation service delivered via the LINE messaging platform (LINE Corporation, Tokyo, Japan) with face-to-face dialogue sessions conducted at local community centers. Healthcare professionals and a community-based organization collaboratively facilitated both components. Rather than evaluating effectiveness, this report focuses on the implementation process and on observational insights from routine operations, including staff field notes, informal debriefings, and participant feedback. The digital consultation service served as a low-threshold entry point, enabling residents to raise health-related concerns early. Over time, some participants transitioned from online consultations to in-person dialogues, which may indicate gradual trust-building and increased confidence in engagement. Face-to-face sessions appeared to foster mutual recognition, peer support, and a shared understanding of community health concerns. Healthcare professionals reported enhanced contextual awareness of residents’ lived experiences. Key challenges included digital exclusion among some older adults, reliance on voluntary human resources, and the absence of formal outcome evaluation. The hybrid digital-physical health dialogue model demonstrates practical feasibility as an implementation approach to support accessible and relational health dialogue in a rural setting. While not an effectiveness study, the findings provide transferable insights for designing community-based, low-threshold health dialogue initiatives that balance accessibility, trust, and sustainability in resource-limited contexts.

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.

Trousseau syndrome is a well-recognized manifestation of cancer-associated hypercoagulability, characterized by recurrent or migratory thrombotic events. Although thrombotic complications have been reported in various malignancies, the clinical characteristics of Trousseau syndrome associated with prostate cancer remain poorly described. This study aimed to systematically review reported cases of prostate cancer-associated Trousseau syndrome and summarize their clinical features. A systematic literature search was conducted in PubMed, Embase, and Web of Science to identify relevant reports describing thrombotic events associated with prostate cancer. Full-text case reports and case series providing sufficient clinical details were included. Six cases met the inclusion criteria. The patients’ ages ranged from 55 to 87 years. Hypertension and dyslipidemia were the most commonly reported comorbidities. In half of the cases, thrombotic events preceded the diagnosis of prostate cancer. All cases with available staging information had stage IV disease, and reported Gleason scores ranged from 7 to 9. Thrombotic events occurred in diverse vascular territories and involved both the arterial and venous systems, including the carotid arteries, deep veins of the lower extremities, the thoracic aorta, retinal veins, and the internal jugular vein. Anticoagulation therapy, particularly intravenous heparin, was the most commonly reported treatment, although clinical outcomes varied among cases. These findings suggest that Trousseau syndrome associated with prostate cancer tends to occur in advanced disease and may occasionally represent the initial manifestation of malignancy; however, interpretation is limited by the small sample size and heterogeneity of reporting inherent to case-report-based evidence. Clinicians should consider underlying prostate cancer in patients presenting with unexplained thrombotic events, particularly in older men. Further studies are required to clarify the optimal management and prognostic implications of cancer-associated thrombosis in prostate cancer.

IntroductionParticipation is a central outcome in community-based rehabilitation, particularly in aging societies where social isolation among older adults is increasing. Community nurses have emerged as key facilitators of social participation in community settings. However, the mechanisms through which community nurses reconstruct participation in everyday practice remain insufficiently understood. This study aimed to clarify how community nurses reconstruct and facilitate participation in community-based rehabilitation.MethodsThis retrospective qualitative study analyzed activity logs and reflective practice records documented by three community nurses working in a rural Japanese community between January and December 2025. Thematic analysis following Braun and Clarke's framework was conducted. Participation episodes were identified and analyzed to examine how participation emerged and was facilitated in everyday community practice. Identified activities were also interpreted with reference to the participation concept of the International Classification of Functioning, Disability and Health (ICF).ResultsA total of 134 participation episodes were identified across multiple participation domains, including community life, recreation and leisure, interpersonal relationships, and digital communication. Four themes were identified: (1) creating participation-ready environments, (2) facilitating reciprocal roles and resident empowerment, (3) reconstructing participation through personal narratives and identity, and (4) bridging participation barriers through relational and structural support. Participation emerged as a relational and dynamic process embedded in everyday community interactions.ConclusionsCommunity nurses play a critical role in reconstructing participation in community-based rehabilitation by facilitating relational engagement, enabling meaningful social roles, and reducing participation barriers. These findings provide empirical insights into how participation can be operationalized in community practice and highlight the potential of participation-oriented approaches in aging societies.

Physical activity is recommended for breast cancer survivors to improve physical function, reduce treatment-related symptoms, and enhance quality of life. However, survivors living in rural areas often face barriers to participating in exercise programs due to geographic isolation, limited access to rehabilitation services, and fewer community resources. Although various exercise interventions have been developed for cancer survivors, evidence regarding their effectiveness and implementation in rural populations remains limited. This systematic review examined the effectiveness and feasibility of physical activity interventions for breast cancer survivors living in rural or non-urban settings. A systematic review was conducted in accordance with a predefined protocol. Electronic databases were searched to identify studies evaluating structured physical activity or rehabilitation programs for adult breast cancer survivors residing in rural areas. Eligible study designs included randomized controlled trials, quasi-experimental studies, and observational studies. Two reviewers independently screened studies, extracted data, and assessed methodological quality. Outcomes included physical function, physical activity levels, health-related quality of life, fatigue, adherence, and feasibility. Findings were synthesized narratively due to heterogeneity in study designs and outcome measures. Seven studies met the inclusion criteria. Interventions included telephone-based counseling, tele-exercise programs, lifestyle interventions, and community-based physical activity initiatives. Most studies reported improvements in physical activity participation, physical performance, lifestyle behaviors, or quality of life. Several interventions demonstrated measurable benefits, including increased physical activity levels and improvements in functional outcomes. Remote delivery approaches, such as telephone or telehealth programs, were frequently used to address geographic barriers. Risk-of-bias assessment indicated generally low to moderate methodological quality across the included studies. Physical activity interventions appear to be feasible and beneficial for breast cancer survivors living in rural areas. Remote and community-based delivery approaches may help overcome access barriers and support participation in exercise programs. Future research should explore sustainable, community-engaged models that promote long-term physical activity and improve quality of life among rural cancer survivors.

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.