Every local government in Japan is seeking to have an integrated health, medical and welfare system to take care of an increasing number of the elderly.
An attempt to develop such a model system called ‘Fukushi no Mori’ was begun in 1987 in Koga City, Ibaraki Prefecture. It was not until 1993 that the land for the project was acquired and the final plans for the arrangement of facilities were drawn up. In March 1994 construction got under way.
This paper discusses the strategies for developing an integrated health, medical and welfare system in this city. The results of a number of detailed research studies undertaken by the authors are also described and discussed.

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A total of 950 urinary stone samples from residents in Aomori Prefecture were analyzed, and the results were examined in comparison with physiological elements in blood and urine. The concentrations of 20 metals in 310 out of the urinary stone samples were measured with the ICP emission spectrochemical analyzer and the role of each metal was analyzed.
The following results were obtained.
1. The frequency of calcium stones in Aomori was 83% and that of uric acid stones was 3.4%. The ratio of struvite stones was 11.4%, which was higher than the national average (7.4%).
2. Serum Cr and uric acid concentrations in the uric acid stone patients were significantly high. This suggested that the renal function in the patients might deteriorate. Uric Ca and P of the calcium stone patients were significantly high.
3. Metal concentrations varied wide in the same type of stones, and the metal contents in uric acid stones and cystine stones were less than those in calcium stones and struvite stones, while the concentrations of most metals in the phosphate stones were over 1.5 times as high as those in calcium oxalate stones.
4. The Ca content in struvite stones ranged from a few to 30% and difference of X-ray permeation was thought to be the cause.
5. The ratio metal concentration in stones and urine ranged from several hundred to several thousand, except for Mg concentration, which was as low as 80. Mg is considered to play an important role in stone formation.

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In our hospital, laboratory technicians have taught diabetic patients the self-monitoring of blood glucose (SMBG) levels with compact glucose analyzers.
We have introduced compact biosensor-type glucose analyzers in addition to conventional compact colorimetric-type glucose analyzers. As a result, the number of the patients doing SMBG have been increasing.
The biosensor type glucose analyzer was proved to have advantages as follows. It was easier to handle, so even elder patients could operate it. A small amount of capillary blood was enough to determine blood glucose levels, so the blood could be collected from other parts of the body than fingertips.The values obtained with this method showed a good correlation to those determined in our laboratory, suggesting their accuracy. Because of these advantages, many patients have switched from the colorimetric-type to the biosensor-type analyzers.
On the other hand, there remain several problems such as inaccurate installation of the sensors and dilution of blood with residual disinfectant.

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During winter months, lotus growers have to harvest edible roots, waist-deep in the muddy fields. In addition to such an external factor as the cold, physical labor involved is so hard that a level of stress is considered high, especially on the cardiovascular system. In this study, we examined how hard the labor is on the cardiovascular system, based on the measurements of hemodynamic parameters taken in the fields while farmers were working. The subjects were comprised of a total of 18 lotus growers-11 men and 7 women-aged between 41 and 66 years (mean: 56.7 years old). During a week before the measurement was performed, a physical examination and an anaerobic threshold (AT) test were given. In the field, each examinee carried an ambulatory electrocardiograph with him or her and levels of blood Pressure (BP), heart rate (HR), and blood saturation-O₂ (SO₂) were measured. During work, the heart rate was elevated significantly, but did not exceed the evaluated maximum heart rate in every case. Immediately after the work, the HR returned to the level measured before the work began. No significant fluctuation was noted in BP, pressure-rate-products (PRP) and SO₂ even during the work. Any sign associated with ischemia was not observed on ECG, either. Soon after the work began, the blood pressure level tended to lower in women compared with that in men and the PRP did not rise in women so much as it did in the opposite sex. However, in two elderly subjects of over 60 years, arrhythmia was noted along with the elevation of blood pressure soon after the stop of the work. These results showed that harvesting lotus roots did not bring about marked changes in the hemodynamic parameters and that the caraiovascular load was slight. However, an adequate health control system should be worked out for the lotus growers of advanced age over 60.

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We reported nine cases of metastatic skin carcinoma experienced at the Department of Dermatology, Obihiro Kosei Hospital during the period from April 1991 to March 1993. Lung was the most common primary lesion (four out of nine cases), followed by uterus (two) and stomach, breast, and kidney (one each). The clinical features of the metastases were classified into nodular (five cases), inflammatory (one case) and sclerotic (three cases) types. Peculiar zoster-like inflammation was seen in metastatic gastric cancer. Pathologically, adenocarcinoma was more common than squamous cell carcinoma. The average interval between the diagnosis of the primary cancers and the development of the skin metastases was about 30±25 months. The average life span after the detection of the skin metastases was 6.8±5.6 months. Poor prognosis of skin metastasis was thus reconfirmed.

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Three main factors that sway the postoperative prognosis of stomach cancer are, the curability of the surgical operation, the depth of the cancer lesion and the stage of the disease. With these factors in mind, we further studied what other factors could influence the long-term prognosis of stomach cancer.
We picked up two categories of patients from our file of stomach cancer cases. Category one; those patients who survived five years or longer after surgery, although the operations for them were not curative, or the depth of the lesion in these patients reached to the serosa, or the cancer was in stage IV. Category two; those patients who died of stomach cancer within five years after surgery, although the operations were curative, or the depth of the lesion reached only the submucosal layer, or the cancer was in stage I.
By comparing these two groups, we found out the factors that influence the prognosis.
1) In the cases of absolutely curative operations, the factors that made the prognosis worse, were that the lesion was advanced, that the lesion existed in the C region, and that the lesion was poorly differentiated histologically.
2) In the cases of noncurative operations, caused by P1, H1, ow (+) or aw (+), factors that brought a good prognosis were, that the lesion was not of diffuse type, that there was no lymph node metastasis, and that lymph node dissection was done effectively.
3) In the cases of early gastric cancer, lymph node metastases made the prognosis worse. Even when the lesion reached the serosa, prognosis was favorable if cancer cells did not invade other organs, had no peritoneal dissemination, or if lymph node dissection was perfect.
4) In the cases of stage I histologically, prognosis was poor when the cancer looked advanced to the naked eye.
5) In the cases of stage IV, when the degrees of lymph node metastasis was slight and lymph node dissection was done adequate, prognosis was good.

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From 1986 to 1991, 49 malignancies were found in sonographic examination of 53, 788 subjects carried out by the Kumamoto Prefectual Welfare Federation of Agricultural Cooperatives. The cases were composed of 12 hepatocellular carcinomas, 11 metastatic liver tumors, 11 renal cell carcinomas, 6 gall bladder carcinomas, 3 gastric carcinomas and 6 ether malignancies including metastatic pancreas tumors and ovarian tumors. A follow-up survey was made in 37 cases. All the case of renal cell carcinoma were found in an early stage and showed the best prognosis; the 2-year survival rate was 100%(n=7). In hepatocellular carcinomas 1-year and 2-year survival rates were 85% and 33%, respectively. Eight of 11 metastatic liver tumors were f rom gastrointestinal malignancies, and prognosis was poor; 1-and 2-year survival rates were 44% and 37%, respectively. Gastric carcinomas were found with lymphadenopathy or the thickening of the gastric wall, so prognosis was quite poor. Abdominal sonography has proved to be a very convenient and safe procedure to find out malignancies in the early stage. In detected (asymptomatic) cases of renal cell carcinoma, prognosis was excellent.

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Control of the blood sugar level is the fundamental treatment for diabetes mellitus. However, it is extremely difficult to effectively control the blood sugar level over a long period, during which complications such as neuropathy, retinopathy and nephropathy may develop. Impaired polyol (sorbitol) metabolism is considered to be a cause of neuropathy among these complications of diabetes. Diabetic neuropathy occurs in a relatively early stage. Its incidence increases with the prolongation of the diabetic condition, and the plight of the patients suffering from extensive tissue damage is profound. In this study, assessment was made regarding the effects of the aldose reductase inhibitor epalrestat, which is expected to reverse the pathogenic mechanism of diabetic neuropathy, on symptoms of neuropathy, erythrocyte sorbitol level, and threshold of vibratory sensibility.
[Subjects] The subjects were 7 male and 4 female outpatients who consistently exhibited spontaneous pain, dysesthesia, and autonomic disorders, or showed abnormalities in the erythrocyte sorbitol level and threshold of vibratory sensibility, and were taking 50 mg of epalrestat (1 tablet) before each meal for at least 6 months. The period of investigation was from October 1992 to March 1993.
[Methods] The subjects were explained about the aim of the study and their informed consents were obtained. They were inquired about symptoms while they were waiting for medicine in the Drug Information Management Office. Data concerning the erythrocyte sorbitol level and threshold of vibratory sensibility were obtained from charts.
[Results and Conclusions] 1) Improvement rates by subjective symptom: 75.0% for spontaneous pain; concerning dysesthesia, 57.1% for numbness of hands and feet, 40.0% for coldness of extremities, 33.3% for hot flushes, 75.0% for hypoesthesia, and 50.0% for itching; concerning autonomic disorders, 75.0% for dizziness on standing up, and 33.3% for abnormal perspiration. 2) Effects by the duration of illness: Improvements were greater as the duration of illness was shorter. 3) Erythrocyte sorbitol level: Improvements were generally unremarkable. 4) Threshold of vibratory sensibility: Fair improvements were observed in general. Neuropathy occurs from a relatively early stage of diabetes, and chronic hyperglycemia is considered to be the most important factor. Regulation of the blood sugar level is essential for the treatment, but if it is impossible, the pain and discomfort of patients may be alleviated by epalrestat, and the administration should be started as early as possible since, in this study, the drug was more effective as the duration of illness was shorter.

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This report concerns a 62-year-old woman with Wegener's granulomatosis. She complained cough, macroscopic hematuria and oligulia. She had a consolidation without a cavity in the left upper lung field, massive proteinuria (2.5 g/day) and massive hematuria. The serum creatinine level was 2.5 mg/dl. The C-ANCA was positive. Renal biopsy revealed crescentic glomerulonephritis. She wa treated with prednisone and trimethoprim-sulfamethoxazole. The lung shadow, proteinuria and hematuria disappeared in one month. The C-ANCA titer also decreased. The use of trimethoprimsulfamethoxazole which may eliminate an infection as a cause to promote Wegener's granulomatosis should be actively included in the conventional treatment.

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Two adult cases of acute tobacco poisoning are reported. Some adult cases occur from intentional ingestion of tobacco, so they give severer indications of poisoning than infant cases which are usually accidental. One person (case 1), who seemed to have taken a nearly fatal dose of tobacco (nicotine) under unfavorable conditions, was carried into hospital some hours after ingestion, but recovered nicely without inducing vomiting and gastric lavege. It was suspected that the tolerance for nicotine and the degree of nicotinic elution might affect his course. Another person (case 2), who had swallowed a large amount of tobacco, also did well. It was supposed that immediate initial treatment was one of the causes for good progress.

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