Amid the swell of the tide of globarization and decentralization, the building of healthy cities and communities has become an increasingly important task of Japan’s health and welfare policy makers. In this article the international trends, results and problems of the healthy cities projects were reviewed with attention focused on the 3rd period (1998-2002) of the WHO healthy cities programs. The strategy and methodology, and the theory and practice of the development of healthy cities and communities were also proposed with stress placed on the need of the symbiotic collaboration between rural communities and urban communities from the viewpoint of policy science.

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We assessed the pediatric emergency care system of our hospital. A total of about 11,714 children were carried into the emergency room during 1998. Their age was young, 33.6% being less than 4 years old and 54.5% less than 7 years old. About half a number of them (50.8%) were received between 5 p.m. and midnight and 75.3% at night. They came to our hospital from two or three secondary medical care areas, the population of which was estimated at 800,000 including 120,000 children. Twenty-six percent of outpatients and 43% of inpatients were those who had first visited the emergency unit. During the year 110 persons entered into our pediatric ICU, 45 persons underwent mechanical ventilation therapy, and an average of 7.4 patients stayed in hospital per day.
We also reviewed the changes of the pediatric emergency care system of our hospital for 20 years. This system has gradually developed. Chronologically, the neonatal intensive care unit was set up in 1983, followed by the opening of the pediatric intensive care unit in 1986, the start of the 24-hour emergency medical care by pediatricians in 1993, the home mechanical ventilation therapy in 1996 and the respite care since 1997. In other words, our system developed from intensive care to primary care and home care—from in-hospital to out-hospital. These changes were the result of our effort to cope with regional features and meet demands : increase of younger children, insufficiency of pediatricians, expansion of medical area in our change and parents’ request for rediatrician’s examination at any time.
In summary, an increasing number of patients who need pediatric emergency care tend to concentrate into one central hospital in a large region. Pediatric emergency care developed into general pediatric medicine including primary care and intensive care and home care.

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We investigated the status of fatigue in a cohort of about 300 citrus fruits farmers in western Japan. The Fatigue Questionnaire for Farmers developed by the Rural Life Research Institute in Tokyo was used in this study. The severity of fatigue was assessed with the fatigue scale for the Questionnaire. The major results obtained were as follows;
1. Fatigue scores at the farming season were not so high. It was assumed that the amount of agricultural work was small at that year because the citrus fruits crop was below average.
2. The scores of fatigue, labor burden, satisfactory and health priority of the subjects at the farming season were not much high in comparison with those of the slack season. However, the fatigue situation indicated different tendencies between the male and female subjects.
3. Comparison among three surveys including this study on farmers producing different agricultural products showed different fatigue situations.
4. Forty percent of the questionnaires recovered could not be used for this analysis because of unanswered items. It was suggested that there is need of developing a questionnaire easier to answer for subjects.

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Laparoscopy-assisted distal gastrectomy (LADG) has been advocated as a minimally invasive operation for early gastric cancer which needs regional lymph node resection. However, since it is technically too complicated and difficult to perform all laparoscopic procedures within the abdominal cavity, LADG has not become the standard surgical procedure for early gastric cancer. Moreover, a skin incision of approximately 5cm is required to allow the reconstruction of the digestive tract after gastrectomy. Therefore, we have developed an operative procedure which we call hand-assisted laparoscopic distal gastrectomy (HALDG). In this procedure we make a skin incision of 6cm, and the surgeon inserts his/her left hand into the abdomen to assist the laparoscopic procedure. The surgeon can move his/her left hand freely, to palpate and explore the organs, as in an open surgery. Therefore, the operation time can be shortened. Our results thus far obtained demonstrated that HALDG was as safe and effective as open distal gastrectomy. HALDG assures the patients a better quality of life, --less surgical trauma, less pain, speedy return to dialy life activities. Thus, it is beneficial to the patients with early gastric cancer. We, therefore, advocate the use of HALDG in such cases.

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The purpose of educating patients with diabetes mellitus (DM) is to facilitate their understanding of the disease and treatment, as well as to motivate the patients to improve their lifestyle. We recently assessed whether the results of psychological tests to investigate the mental status of DM patients were useful in obtaining a better outcome of education. The subjects were 75 DM out patients who were receiving treatment at out hospital (age range : 15-85 years, mean age : 66 years). The psychological tests were performed during a diabetic seminar held on February 26, 2002, using the Center for Epidemiologic Studies Depression Scale (CES-D Scale) and the Coping Inventory for Stressful Situation (CISS).
On the CES-D scales, 20 points or higher scores were marked by 16 patients (21.3%), indicating a strong tendency to depression among DM patients. Assessment by the CISS showed a higher score on the task-oriented coping scale (T scale) than on the other scales (p<0.05), suggesting that DM patients are well-oriented towards the continuation of treatment. The CES-D Scale score tended to be higher in patients with an uncontrolled HbA_1C (≥8%) (p<0.05), suggesting that a persistent depressed status is associated with poor glycemic control. The results of these psychological tests appeared to be useful in working out a more effective educational program for DM patients.

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Before we moved into the present hospital building in October 2000, we took the opportunity to thoroughly review our medical equipment management system and developed a new centralized management system. With the introduction of the new system, we have made a complete list [an inventory] of medical equipment on hand from small-size instruments to large-scale machinery. We have now become able to grasp the frequency of use of ME, the cause of mechanical trouble, the cost of repairing and so forth. In the future, this system will be further improved so as to enable us to incorporate a labor-saving procedure for equipment lending into the system, share information with other departments, and work out a net working rate and repair rate to make purchasing or disposal plans.
Medical care and health services of today cannot be provided without use of modern medical equipment. Under the circumstances, the prevention of accidents and grasp of the optimum amount of machinery and equipment are important. At the same time, the reduction of cost by adequate maintenance work is essential. We think that our centralized equipment management system will work effectively and serve the purpose.

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An increasing number of children who have ADHD are visiting pediatric clinics. In this study, we focused on the behavior of ADHD children in different situations.
The behavior of ADHD children was evaluated with a specially designed checklist in a person-to-person situation in which the subject was face to face with the clinical psychologist at the counseling room and in a group situation in which the subject participated in an outdoor program organized by the Department of Pediatries of Enshu General Hospital.
In the person-to-person context, all of the performance scores with respect to attention-deficit, impulsivity, hyperactivity and difficulty with communication were decreased after psychotherapy. This suggested the regular person-to-person therapy with medication could improve the behaviors and development of ADHD children. On the other hand, the hyperactivity score was increased in the group context because of a lot of stimulation. These findings suggested ADHD children’s behavior changes according to the situation, and that we should take care of them with this fact in mind.

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A 72-year-old man who suddenly felt an excessive thirst and developed pollakisuria and high fever on Sept. 29, 2001. A general practitioner initially diagnosed him as having urinary tract infection on the same day. Vomiting and unconscionsnes occurred on Oct. 3. He was brought to our hospital by ambulance. Laboratory data on admission showed plasma glucose of 1110 mg/dl, blood pH of 7.167 and HCO₃^- of 7.6mmol/L, and positive urinary ketone bodies, compatible with diabetic ketoacidosis. Serum amylase was elevated, but he had no symptoms of acute pancreatitis. Insulin therapy was started immediately and hyperglyvemia was improved. He has never had diabetes mellitus and his HbA_1c was normal (5.3%). His urinary C-peptide was very low (2.4 μg/day) and diabetes-related autoantibodies including anti-GAD, IA-2 antibodies and ICA were negative. So his case was diagnosed as fulminant type 1 diabetes mellitus. Fulminant type 1 diabetes, which has been brought to light by Dr Imagawa’s group, is characterized by near-nomal HbA_1c despite diabetic ketoacidosis, rapid loss of insulin secretion and absence of diabetes-related autoantibodies.
Great care is needed to recognize the patients with fulminant type 1 diabetes among the elderly with symptoms of urinary tract infection. Here, we reported the case of an aged man who developed aypical fulminant type 1 diabetes.

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Four patients with fulminant myocarditis (two males and two females, age 21-67 years old) were examined during 1995-2001. Fulminant myocarditis was diagnosed based on clinical features, abnormal electrocardiographic and echocardiographic findings, and increased serum enzyme levels. In three of four cases, the diagnoses were confirmed histologically in autopsy. All four patients had flu-like symptoms and fever at the start. One patient died suddenly next day. Other three patients went into cardiogenic shock five and seven days after the onset of symptoms and hospitalized, and treated with temporary pacing, steroid pulse therapy, catecholamine (in all three patients) and percutaneous cardiopulmonary support : PCPS (in one patient), but they died within ten days. Electrocardigrams showed ventricular escape rhythm, ST elevation associated with Q wave, and low voltage of the QRS complex. Markedly increased serum enzyme levels, severe metabolic acidosis and disseminated intravascular coagulation were thought to be indicative of poor prognosis. Early recognition of cardiac involvement and using of PCPS without hesitation in an acute phase could improve the outcome of fulminant myocarditis.

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A new edition of infection control manual was brought out after months of reviewing the utility of the preceding edition. Using the new manual, a series of study meetings were held with the aim of raising awareness among the personnel of infection prevention.
Preventive measures have been changing with rapid advances in medical treatment. The old manual, which had undergone revision repeatedly, was not utilized fully.
In view of the situation, questionnaires were distributed to all the members of the hospital staff (n=447) to investigate the reasons why the manual had not been utilized. Although many respondents were of the opinion that the old manual was out of date, too thick, and unreadable, 44.7% said they had used it. 55.3% answered that they had asked their superiors or colleagues out of necessity. Based on these results, we started making a compilation of a new manual, easy to understand and friendly to the users. It took about six months to complete it. Copies of the new manual were given to all the staff members. In the study meetings, various subjects were taken up for discussion, including the definition of nosocominal infection, “universal precaution,” how to effectively wash your hands, how to keep the rest rooms clean, how to wear the gloves and mask, and so forth. We believe that the personnel’s consciousness of infection prevention was further raised by holding the study meetings.

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As a management improvement tool useful for cost containment and adaptable to the trend of reform in recent years, we introduced the SPD system of medical materials. Since there had been no precedent for the introduction of the SPD system in the hospitals affiliated with Kouseiren and even for the dealer it was the first trial, an original system was built. The quantity of materials in stock was fixed by entrusting, so-called the shelf control system. This system has been left in charge of one hospital employee and one individual employed by the dealer.
The condition at the time when this system was introduced was not to increase personnel but to lower costs. The maintenance costs of this system were as cheap as 137,700 yen per month on a five-year lease. As a result, the quantity of inventory at the time of the term-end settlement of accounts reduced by about 18 million yen. Moreover, in marked contrast with increased income, the amount of money expended in the purchase of medical materials decreased from that in the pervious year. Though the number of items used in each department has increased by 480 items now from the start, the inventory is 0 yen.
This system is very useful especially for the inventory management of specific insurance medical materials, because it can take in insurance claim data on MO (Magneto Optical Disk), compare it with the purchase data of materials and check the income-and-expenditure balance of specific insurance medical materials immediately. The sum of the amount of temporary stock curtailment for the past two years and six months and the annual purchase curtailment amount was 93,380,000 yen.
It is concluded that the introduction of the SPD system has contributed much to the improvement of inventory management.

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