The coronavirus disease (COVID-19) pandemic has complicated the work of general physicians due to the vagueness of fever standards. Because of the high virulence of the causative virus, the disease is rapidly spreading worldwide, even reaching the rural areas in Japan. During the first wave of the pandemic, the Japanese government set the standard as a temperature of 37.5°C lasting for more than four days. However, after the government deleted this standard from its website, there was confusion in the medical institutions, as they struggled to set their fever standards. As a result, social fear might force healthcare professionals to bring down the standard for fever to increase the sensitivity and identify patients with COVID-19 more accurately. During the second wave, the fever standard was set at 37°C to enable high sensitivity. Subsequently, general physicians had to approach many people with temperatures higher than 37°C who came to the hospital seeking treatment for their symptoms or to visit their families. People seek to avoid contracting the COVID-19 infection for health-related and social reasons. When there is a possibility of healthcare professionals testing positive, hospitals may have to shut down and face criticism from society, as the mass media generally accuses these hospitals of mismanagement.

Objective: The traits of the inhabitants of rural areas could affect clinical improvements. In the rural areas of Japan, a feeling of competitiveness often exists between the members of a community; this competitiveness could prompt patients to exert efforts in improving their health. This study aimed to assess the effects of competitiveness on the clinical outcomes of patients with diabetes.Patients and Methods: Between December 2014 and December 2015, a pilot study was conducted among patients with diabetes to assess the effects of an intervention on improvements in self-care, quality of life (QOL), and hemoglobin A1c (HbA1c) values. The intervention included showing each participant a histogram of the HbA1c levels of all patients visiting a clinic in the remote island as well as the location of their own HbA1c level on the histogram. Once every 4 months, the patient’s HbA1c level was assessed by conducting a blood test, and the self-care agency questionnaire 30 (SCAQ30) was administered by a community health nurse. After 12 months, changes in HbA1c values, SCAQ30 score, and MOS 36-item short-form health survey score were evaluated.Results: Sixty-four participants (mean age: 63.6 years; male-to-female ratio: 35:29) were included in the final analysis (follow-up rate: 71.1%). In participants with HbA1c values ≥ 8% and < 8% at baseline, the HbA1c value decreased by 1.39 (p < 0.001) and 0.12 (p = 0.137), respectively, and the mean SCAQ30 score increased by 14.94 and 6.39 points (p < 0.001), respectively. Furthermore, in participants with an HbA1c value ≥ 8%, the mean mental component summary score increased by 5.64 points (p = 0.019), and the mean role/social component summary score decreased by 6.04 points (p = 0.022).Conclusion: The continuous stimulation of competitiveness may help improve the health conditions of patients with diabetes. Moreover, collaboration between rural clinics and community health nurses may also be important.

Objective: Community-based medical education (CBME) serves as a complement to university medical education, and it is practiced in several urban undergraduate and postgraduate curriculums. However, there are few reports on CBME learning content in rural Japanese settings.Materials and Methods: This research aimed to clarify learning content through semi-structured interviews and qualitative analysis of second-year residents who studied on a remote, rural island located 400 km from the mainland of Okinawa, Japan. Analysis was based on Steps for Coding and Theorization (SCAT).Results: Fifteen concepts were extracted, and four categories were generated: a strong connection among the islanders, the necessary abilities for rural physicians, islander-centered care, and the differences between rural and hospital medicine. In contrast to hospital medicine, various kinds of learning occurred in deep relationships with the islanders.Conclusion: Through CBME on a remote island, the residents learned not only about medical aspects, but also the importance of community health through the social and cultural aspects, whole-person medical care in a remote location, and the importance of reflection in their self-directed learning.

　　We encountered a case of Japanese spotted fever in Unnan City, Shimane Prefecture. A 77-year-old woman visited our hospital complaining of fatigue. Initially, we diagnosed tsutsugamushi disease based on the constellation of presenting symptoms and clinical signs including fever, systemic erythema, and an eschar. However, the eschar was submitted for polymerase chain reaction analysis and was found to be positive for Rickettsia japonica. The final diagnosis was Japanese spotted fever. To the best of our knowledge, this is the first report of Japanese spotted fever in Unnan City, and there is a possibility that the condition has spread not only in the north of the prefecture but also in the south. This may be due to the widening habitat of ticks harboring R. japonica. Interestingly, the wild boar, a suspected vector, has expanded its habitat to the south of the prefecture. Research on the ecology of the wild boar is warranted.

Objective: To report the first case of ciguatera-associated rheumatoid arthritis in Japan.

Patient: A 53-year-old man presented to our clinic with morning stiffness and pain in the fingers and wrists.

Results: For six months, he had suffered from chronic pain in both hands and shoulders caused by ciguatera poisoning. He was referred to a local general hospital and diagnosed with RA.

Conclusion: When synovitis becomes evident in chronic ciguatera poisoning, reevaluation is necessary, including investigation of chronic arthritis, which might be associated with the onset of RA.

Objective: To clarify the scope of practice on rural islands of Okinawa.

Patient: A 59-year-old man presented to our clinic with shortness of breath. He was intubated due to acute respiratory failure caused by severe pneumonia. We could not transfer him owing to bad weather, and had to continue patient care in the clinic for more than 24 hours.

Discussion: In remote regions, rural physicians may require a broad scope of practice from primary to tertiary care, in addition to preventive and end-of-life care.

Conclusion: This case illustrates the current state of emergency care and unique scope of practice on rural islands of Okinawa.

Introduction: Our aim was to determine the relationship between pediatric wheezing attacks and sugarcane harvest work.

Methods: We recorded daily symptoms, including wheezing attacks, from 167 children attending kindergarten, elementary and junior high school on Minamidaito Island, Okinawa. We calculated wheezing attack frequency every two months and checked the seasonal changes. Logistic regressions were performed to examine the relationship between wheezing attacks and background factors.

Result: The collection rate of the check sheets was 62.5%. The median age was 7.5 years old, male-to-female ratio was 8:7 and the percentage of children with asthma was 36%. Wheezing attack frequency during sugarcane harvest work (January-March) had increased significantly compared with other periods. There was a number of wheezing attacks even in children without asthma.

Conclusion: There is a possibility that sugarcane harvest work is related with pediatric wheezing attacks.