In Japan, the number of dialysis patients as of the end of fiscal 2007 has hit the 275,000 mark. The nation is now ahead of the rest of the world in the number of patients per million population. The largest problem that confronts us is that the enormous cost of dialysis is putting a great strain on the nation's finances. In addition, it should be mentioned that the quality of life of dialysis patients is aggravating. It is very rare for renal disease patients to receive kidney transplants, because only 200 kidneys are offered per year in Japan. So most of the patients have no choice but to depend on dialysis for the rest of their life.
  In the treatment of chronic kidney disease (CKD), it is important to for physicians to delay initiating dialysis as much as they can in Japan. In 1987, I began the programmed treatment of patients in a predialysis state with two nephrologists. The treatment is based on the “Toride guidelines for CKD”. There is an annual meeting of patients. Laboratory data and the history of medication are preserved in sheets.
  In the CKD clinic of our hospital, there are many devices for time-consuming. Full laboratory data apear quickly on the computer panel, and a clerk enters main data in patients, CKD records.
  The principles of the clinic iuclude control of office blood pressure and home blood pressure, mild restriction of protein intake, salt intake restriction, monitoring the diet from the data of 24 hours urine collection, control of hemoglobin concentration, serum bicarbonate and phosphate concentration. Reduction in urine protein excretion to less than 0.5 gram per day is done by dietary protein restriction, control of blood pressure and administration of angiotensin converting enzyme inhibitor or angiotensin receptor blocker.
  The outcomes of the Toride Cohort Study in the past 21 years are as follows:
1. Reduction in medical cost by slowing the progression of CKD;
2. Reduction in the dialysis-to-non dialysis rate;
3. Appearance of the “arrested” or “remission” cases; and;
4. Detection of the new risk factors for progression of CKD such as hyperphosphatenia and metabolic acidosis by multivariate analysis.
  There is a bare possibility open for a CKD patient to receive the “right” treatment of CKD, because only four to five clinics adopting the Toride guidelines are available in Japan.
  Physicians in CKD clinics have to judge and adjust many variables. The clinics spend plenty of time and effort on the treatment of CKD.
  In Japan, the medical fee in clinics is dependent on the number of visiting patients and on the number and quality of laboratory examinations, so the physicians keep away from CKD clinics.
  For the reduction of cost of dialysis, spread of “right” treatment is needed. For spread of the treatment, additional medical fee per patient visit is necessary as incentive.

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  We now enjoy an affluent, comfortable and efficient lifestyle that human beings have long dreamt of. And yet we feel lurking anxiety about the present and the future. Some youths do not have any definite aim in life or foresight, and some people are alarmed by nature destruction, environmental pollution, erratic climate change, global warming and so on.
  When it comes to medical care, there are serious shortages of physicians in rural areas and in specific departments such as obstetrics and gynecology and pediatrics. The average life expectancy of Japanese has increased, but various forms of disease including cancer and dementia debase the quality of life.
  Affluent urban life today is supported by the countryside, which undertakes foodproduction and preserves the natural environment. The government should make more efforts to correct disparities between urban and rural areas in population, economics, culture, and medical care.
  We live now at a crossroads in the 4-billion-year long history of life on the earth. The thread of genes has continued to the pressent. It must be handed down to posterity. Advances in medical technology have contribute greatly to the protection of our life and genes. Indigenous forests have unsophisticatedly fostered our health, physical and mental, soul, and have protected our genes.
  We humans and other animals alike are consumers in the ecosystems on the earth. Greenplants are the only producers, and bacteria and fungi are decomposers. Green plants, especially multi-layered native forests that enrich green plants, are the very foundation of human existence.
  Japanese were particularly zealous in protecting and bequeathing native forests in each community, and reforesting after destroying forests to construct paddy fields, roads and villages just as other peoples did in other partsof the world.
  Native forests in most areas of Japan are laurel forests. Main tree species of laurel forests have evergreen thick watery leaves and deep taproots grabbing thesoil. So, multi-layered native forests have the function of environmental protection including noise insulation, windbreaking, air and water purification, and water retention, as well as the function of disaster mitigation, minimizing damage from storms, earthquakes, fires and tsunamis.
  Forests absorb CO₂ in the air through photosynthesis and fix carbon as an organic compound in the tree body. This helps curb global warming. In the age of deteriorating biodiversity, it is worthy of special mention that there are so many tree species and so many species of birds, insects and small animals in an indigenous forest as well as bacteria and fungi living in the soil. Thus, indigenous forests maintain rich biodiversity, and are the real green environments that protect our life, heart and genes.
  However, indigenous forests are rapidly vanishing from almost all the areas of the world. Where native forests still remain, they should be preserved. Where native forests are destroyed, they should be restored and regenerated by all possible mean. We conduct phytosociological field surveys to determine main tree species of a given district, nurse their potted seedlings until theroot system fully develops in the containers, and plant them mixed and densely with local citizens. In this ecological plantation survival rate is good, and seedlings grow steadily to form a quasi-natural forest in 10-15 years.
  Every one of us should plant seedlings for ecological reforestation here and now, especially around hospitals and clinics, and spread the reforestation movement to the whole world to protect our own life, heart and genes.

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  The goal of palliative care is to soothe or relieve the patients with serious illness of their suffering and to improve the quality of their life. It integrates the physical, psychological, social and spiritual aspects of patient care into a comprehensive whole. Doctors and other medical workers talk with the patients by providing appropriate information and explanations and care should be carried out according to the patients' wishes. The care team should confirm their wishes at every opportunity since the patients' wishes can change with time. The presenters who were actually involved in medical care or nursing care discussed how to solve the problems of palliative care and end-of-life care.

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  The comprehensive daily payment system by DPC developed the standardization of medical care and cost-effectiveness. We can exchange intelligence of other hospitals through the benchmark. Clinical pathways were useful for both the standardization and cost-benefit analysis. The production of pathways improved the communication between hospital employees. The excessive shortening of the average length of hospital stay decreased the rate of bed usage. The DPC payment system leaves much room for improvement in the quality of medical treatment and care.

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  We discussed the current state of the emergency care of pregnant women and better ways to solve the problems confronting obstetricians and hospitals in our country.
  The basis of this problem is that doctors specialized in obstetrics and gynecology are working hard at high risk of being sued, resulting in the rapid decrease in the number of obstetricians. It has become difficult for many hospitals to maintain the department of obstetrics and gynecology. In other arords, it boils down to how to increase, or at least not to decrease the number of obstetricians and how to use present working doctors efficiently. By so doing, we could take in more emergency patients. To incease the number of those who choose obstetrics and gynecology, we should emphasize attrctive aspects of obstetrics and gynecology to students in early grades of medical schools. To assist the women doctors' return after maternity leave in taking care of their child, 24-hour day nurseries are necessary. Construction of the systems of short time work to reduce their hard and long-time load is also needed.
  In addition, the effective regional hospital association and cooperation should be encouraged and prompt maternal transportation should be achieved as much as possible. Doctors of different clinics or hospitals are expected to join forces to replenish the work of a regional perinatal central hospital. There are many of the medical treatment lawsuit when the newborn baby with cerebral palsy is born. This is one reason why the doctors keep away from obstetrics. A new system of the nofault amends system may be established by which the load of medical providers and patients can be reduced. Increased salary for obstetrician may be effective to induce doctors to obstetrics. These points were discussed.

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  Recently, the Jepanese government have advanced home medical care services. They former health care system was reformed to place much emphasis on home care. But there are many problems:for instance, the difficulty of coordinating discharges from a hospital and cooperation between hospitals and regional clinics. Especially, the biggest problem was that medical staff in wards do not have knowledge of the realities of home medical care and visiting nursing services. In this session, we invite four persons who are actively involved in the front lines in the field of home medical care. We expect they will speak about realities of home care and make you understand the potential of home medical care.

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  Progress in chemotherapeutic strategy has significantly decreased side effects of the drugs used and greatly added to survival rates for ovarian cancer. On the other hand, the occurrence of myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) has been reported after long-term chemotherapy. We encountered a case of therapy-related MDS that developed as a consequence of chemotherapy. A 59-year-old woman (gravida 2, para 2) stage IIIc ovarian cancer received three courses of paclitaxel and carboplatin therapy (TC) prior to primary surgery, and 16 courses of weekly TC as adjuvant chemotherapy. She exhibited pacritaxel-associated hypersensitivity reactions in the last course, so that chemotherapy was discontinued. Following three mouths of remission, a sudden rise in her tumor markers and an increase in the size of her pelvic lymphonode were discovered on PET-CT. She recieved multiple courses of chemotherary of docetaxel/carboplatin, weekly docetaxel, docetaxel/briplatin and Gemcitabin/Irinotecan between four months. In 30 months after diagnosis, complete blood count showed hemoglobin 7.7 g/dl; white cell count 4,310/μl; and platelet 7.9×10⁴/μl. A bone marrow examination revealed MDS. She then decided against further chemotherapy, opting instead for palliative care. Fortunately, up to the present, she has not developed AML.

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