The JA Aichi Welfare Federation consists of 8 hospitals, comprising 4 large and 4 mediumsized hospitals. The estimated population of the medical areas that the large hospitals serve has yet to decline notably. In the West Nishimikawa Medical Area, where Anjo Kosei Hospital is located, and in the North Nishimikawa Medical Area, where Toyota Kosei Hospital is located, the population is expected to remain mostly stable even up to 2040.
Together with Miyoshi City, Toyota City (population 480,000), where our hospital is located, is in the North Nishimikawa Medical Area and is located to the east of Nagoya City. Due to the Great Heisei Consolidation, the vast mountainous area to the northeast of Toyota City has been incorporated into the city. Then, including the urban area that historically made up the city, this medical area is the largest in Aichi Prefecture. The aging rate is increasing rapidly, and medical demand is expected to increase about 20% (an estimated 140,000 people) by 2040. Therefore, the issue that must be addressed is how to maintain the medical system in the face of rapid population aging in urban areas as well as in the vast mountainous areas,where the population has declined significantly.
　Our hospital opened as Kamo Hospital in 1947. After moving to its current location in 2008, the hospital was renamed Toyota Kosei Hospital. Although net income was significantly negative shortly after the move, total revenue has been steadily increasing since then. Net profit returned to being positive, but the profit margin of medical practice did not readily increase. In the first hospital director's inaugural year, net profit was only 1.5%. Partly because our hospital moved from the center of Toyota City to its northwestern outskirts, the decrease in patients from the city center and the southern part of the city had an effect.
　We are promoting changes in hospital management in line with the Community Medicine Concept, promoting an increase in the number of new patients from adjacent medical areas, increasing the referral rate, and promoting reverse referrals to streamline outpatient care functions. By optimizing the number of outpatients, we are seeking to allocate human resources to inpatient treatment and increase inpatient income. Thanks to these efforts, net profit has exceeded 8% in 5 years up to fiscal year 2019.
　Although we had been aiming to implement reforms to further improve the quality of medical care in the next few years, the impact of the COVID-19 pandemic this year has been immeasurable and has left us struggling. Hospital management has been strongly impacted since April, and no measures have been taken to compensate for the decline in medical income. As the end of the pandemic is unpredictable, the hospital itself needs to change its behavior. At the same time as managing COVID-19 patients in the community, securing income for continuing medical care is an important issue. Community medicine cannot be protected if the hospital cannot survive.

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　Here, we report 3 cases of conservatively treated ischemic colitis with hepatic portal venous gas. In Case 1, an 84-year-old man visited the emergency department because of fatigue, vomiting, and upper abdominal pain. In Case 2, a 72-year-old man was hospitalized for rehabilitation in another hospital following cervical spine trauma. He had diarrhea and mesogastric pain for 2 days and was transferred to our hospital. In Case 3, an 89-year-old woman visited the emergency department because of upper abdominal pain and vomiting. In all cases, we diagnosed the illness as ischemic colitis with hepatic portal venous gas based on computed tomography findings, and the vital signs of all patients were stable. They were treated conservatively. They were able to resume oral intake and were discharged or transferred to another hospital. Hepatic portal venous gas has been considered a poor prognostic sign of severe diseases such as intestinal necrosis. However, recently, reports of cases treated conservatively have been increasing. Conservative treatment may be selected for ischemic colitis associated with hepatic portal venous gas taking into account the patient’s general condition.

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　A young child with VACTERL association who refused oral intake and had relied on gastric tube feeding for almost all of her nutritional intake since birth was initially managed with nutritional guidance based on the assumption that refusal was due to oral hypersensitivity. However, no improvement was observed in the refusal of oral intake, and her inherent developmental delay and bilateral hearing loss prevented the continuation of nutritional guidance. A speech-language-hearing therapist was then consulted to assess the patient’s swallowing function, and the diagnosis was that the lack of experience of oral intake itself and the dependence on tube feeding were more likely causes of the refusal than oral hypersensitivity. We therefore decided to use the approach proposed by Tazumi et al. for stepwise management of eating disorders requiring tube feeding in young children. This allowed us to create a step-bystep management plan toward achieving oral intake, resulting in gradual but significant changes in the patient's eating behavior. Although oral intake has not been achieved as of the time of writing, we are continuing to manage the patient with this trial-and-error approach.

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　We encountered a case in which improving limited knee flexion was difficult after surgery for a femoral shaft fracture. A woman in her 20s sustained polytrauma including a femoral shaft fracture. Anterograde intramedullary nailing of the femur was performed at another hospital on the day after the injury, and 75 days later she was transferred to our hospital for rehabilitation. The referral document indicated the fracture was an AO type C2 fracture, and postoperative plain radiographs showed that one of the locking screws in the distal femur was inserted from the anterior to posterior side. She was discharged to home at 90 days post-injury, but knee joint flexion was still limited to 95°, and she complained of pain in the final flexion range where a side-stop screw was inserted at the front of the knee. Imaging and physical findings indicated that knee flexion was restricted by contracture of the suprapatellar supporting tissues, so an approach focusing on these tissues was added to her outpatient exercise regimen. As a result, knee flexion was improved to 150° at 140 days post-injury and she had no interference in activities of daily living.

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　We began providing comprehensive cardiac rehabilitation for congestive heart failure (CHF) in 2014 at our institution, using an original pamphlet and heart failure notebook to provide life guidance for CHF. However, the life guidance rate was lower in 2017 (61%) than it was in 2014 (77%). The objective of this study was to investigate the awareness of life guidance among nurses. We administered a questionnaire survey regarding life guidance to 28 nurses in December 2018. Among the 27 respondents, 26 nurses (96%) had high motivation and 21 (80%) felt a sense of accomplishment. Responses to the “most important point in life guidance” were “understanding living condition” by 14 nurses, “heart failure notebook” by 9 nurses, and “guidance using the pamphlet” by 6 nurses. Fifteen nurses (58%) felt that the guidance had become routine in nature, and 5 nurses (19%) were worried about their instruction. The nurses were motivated to provide life guidance, but they also felt that the guidance had become routine because they had been providing the same guidance for many years. We consider that the factors related to the lower life guidance rate are the routine/repetitive nature of the guidance and concerns about instruction. Going forward, we need to review the content of the guidance and the teaching approach.

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