The objective of this report is to clarify the importance of cooperation between hospitals and sports gyms. As a result of the rapidly aging society in Japan, considerable emphasis has been recently given to extending healthy life-span. On the other hand, Japanese people tend not to pay attention to preventive measures, and due to the protection offered by universal health insurance coverage, are passive regarding therapy for conditions such as knee osteoarthritis (KOA). In August 2011, we launched a team to provide total support for KOA (team TS-KOA) with the aim of achieving active participation of patients in therapy for this disorder. The team consists of orthopedic surgeons, nurses, nutritionists, radiologists, and physical educators from an adjacent sports gym. First, we prepared simple and easy referral forms to the gym, and then established a correspondence procedure using the e-mail function in the electronic health record system. The exercise protocol for KOA at the gym was decided not only by doctors but also by a physical therapist and physical educators at the gym. Following the start of this program by team TS-KOA, the number of patients introduced to the gym from the hospital increased from 71 to 209 patients per year. However, several steps remain to be solved；for instance patients cannot use the gym during their hospital stay because treatment covered partially by insurance is not allowed in Japan. It is therefore necessary to gather data on the efficacy of TS-KOA in order to create a legal environment for cooperation with sports gyms.

In recent years, the number of the cases of late child-bearing is showing sharp increase. Accordingly, the indirect obstetric death caused by accidental complications such as malignant tumor and cerebrovascular disorder, accounts for 30 to 50 percent of the total maternal death which accounted only 10 percent before. Although the incidence of cerebrovascular disorder in pregnant women is low, immediate treatments are required after the onset, since maternal mortality is quite high and even if they survive, the rate of neurological sequellae is similarly high. In addition to that, pregnant women are at higher risk for complications of pregnancy induced hypertension, HELLP syndrome, and disseminated intravascular coagulation. The promotion of maintenance and management of these patients in collaboration with other departments (not only with department of obstetrics and department of neonatology but also with department of neurology, department of intensive care, department of anesthesia, and department of neurosurgery) is of great significance. In our hospital, we have experienced the case of intractable and recurrent convulsions after the occurrence of eclampsia, and asymptomatic cerebral infarction had remained post-incident. Consultation was held with the department of neonatology and other related departments and the criteria were created for management of eclampsia and a flow chart for management of convulsion. There were two cases of eclampsia after introducing those systems, and in both cases, patients recovered without sequellae. Therefore, for pregnant women of cerebrovascular disorder to survive without sequellae, immediate response is essential and prior establishment of the system for cooperation and strengthened team medicine is critical.

In April 2009, for the purpose of risk management in central venous catheterization (CVC), the ex post facto report system was introduced in our hospital. An analysis of presented reports found that the annual total number of CVC has been significantly decreasing in three years and in addition that the proportions of selecting multi-lumen catheters and landmark-depending introduction of needles are trending downward. On the other hand it was revealed that over-three-time stub forbidden in our CVC manual has remained and that acquirement of informed consent in advance and maximum sterile barrier precaution cannot be executed perfectly. Together with continuing this report system, actions are needed such as repetitious induction of the manual, periodical workshop on safe maneuver and case conference when some accident in relation to CVC occurs.

Formaldehyde (FA) is known to be toxic to humans as an irritant of the skin, conjunctiva and respiratory epithelium, a cause of psychic symptoms, and a carcinogen. However, not much care has not been given to FA concentration in a preparation room for surgical specimen. Japanese Ministry of Health, Labor and Welfare tightened the FA-regulations in March 2008. FA concentration in our preparation room for surgical specimen was occasionally above the maximal required value (0.1 ppm). The causes of high FA-concentration were as follows：1) insufficient gas exhaust system, 2) non-localized manipulation of FA, 3) narrow working space making the working time long, 4) incomplete seal of the specimen box containing FA. Following measures were conducted in reducing FA concentration in the room：1) improvement of gas exhaust system including increased power of the exhaust fan and introduction of intensive exhaust system on the FA desk, 2) restricting FA manipulation at only close proximity to the intensive exhaust system, 3) widening of the working space allowing shortened working time, 4) new completely sealed box for surgical specimen. Based on these measures, FA concentration less than 0.01 ppm (one-tenth the maximal required value) was recorded. Our attempts for reducing FA concentration in a preparation room for surgical specimen were successful and may protect surgeons from FA toxicity.

Out of approximately 8,700 hospitals nationwide, about 800 high-volume hospitals with more than 400 beds have been steadily introducing electronic medical record (EMR). It has a possibility of changes in outpatient congestion and/or consultation behavior at the induction period of EMR, because most hospitals transfer to EMR from paper record without transition period.

In 2008, University Hospital, Kyoto Prefectural University of Medicine also introduced EMR without transition period and no limitation of the consultation for outpatient department (OPD) was done. We ascribed 2012 to stabilized period of EMR. And we examined retrospectively if changes in outpatient congestion and/or consultation behavior could have occurred at the induction period by comparing their parameters to those at the stabilized period.

Both in induction and stabilized periods, significantly low levels of outpatient number and time spent in hospital for OPD were noted on Fridays. In both periods, even when small number of patients visited the OPD, their time spent in hospital was not always shorter than the others. In fact, trend had persisted that the later the patients visited our hospital, the smaller the number of patients waiting, and the shorter the time spent in hospital. Time spent in hospital for OPD was significantly longer in stabilized period when comparing to the induction period. However, when adjusted by outpatient number, duration was almost the same in both periods.

At the time of EMR induction, congestion degree seemed to have no change according to the day and time, even in university hospitals without limiting outpatients.

To accomplish the appropriate medical care based on informed consent, second-opinion consultation is recommended. Although the patient is requested to bring a referral letter from the original physician and he/she is expected to return to the physician after the second-opinion consultation, this process may not be always obeyed. Therefore, to clarify the current status and problems of the second-opinion consultation in urological diseases, factual survey was performed.

A total of 164 patients who visited the second-opinion clinic at Department of Urology, Tokyo Kosei Nenkin Hospital from November 2004 to March 2011, were included. Characteristics of the patients, methods of consultation and outcomes were investigated and analyzed.

Of 164, 155 were male and 9 were female patients with a mean age of 68.4 years (range：33-94). The present addresses of the patients were Tokyo Prefecture in 90, Chiba Prefecture in 25, and Kanagawa Prefecture in 13, resulting in 143 cases (87%) in Kanto Area. Family member(s) visited without the patient in 8 cases (5%) and the patient visited without a referral letter in 23 cases (14%). The most common diagnosis was prostate cancer (135 cases, 82%), and the majority (155 cases, 95%) was urological malignancy. After consultation, 93 cases (56%) returned to the original physician, 37 cases (23%) decided to receive treatment at our hospital, and the results were unknown in 34 cases (21%). The patients coming from outside Kanto Area, bringing a referral letter, and of prostate cancer, more frequently returned to the original physician.

The majority of the patients who visit the second-opinion consultation had urological malignancy, especially prostate cancer. If the patient was convinced of the treatment option, he/she would certainly return to the original physician.