Many hospitalized patients undergoing rehabilitation are often complicated by malnutrition and sarcopenia, which hinder their rehabilitation.　Since nutritional management is essential to improve these conditions, the concept of “rehabilitation nutrition” has been proposed in recent clinical practice.　The rehabilitation nutrition requires evaluation by a holistic assessment based on the International Classification of Functioning, Disability and Health （ICF）, evaluation of the presence of nutritional disorders, sarcopenia, and excess or deficiency in nutrient intake, diagnosis of their cause, and setting appropriate intervention goals, and defined as “nutrition care management in consideration of rehabilitation” and “rehabilitation in consideration of nutrition” to improve nutritional status, sarcopenia, nutrient intake, and frailty of the disabled and frail elderly to maximize function, activity, participation, and quality of life.　To effectively implement rehabilitation nutrition, the rehabilitation nutrition care process consisting of five steps is useful, and it is recommended that this cycle be implemented through collaboration among multiple professions.　The recently developed Japanese clinical practice guidelines for rehabilitation nutrition in cerebrovascular disease, hip fracture femur fracture, cancer, and acute illness.　The number of elderly patients undergoing rehabilitation is expected to increase, which will inevitably increase the demand for rehabilitative nutrition.　In order to establish rehabilitation nutrition in society, promotion of high-quality research as well as the dissemination of rehabilitation nutrition will be essential in the future.

In chronic renal failure patients and dialysis patients, hyperphosphatemia and hypovitaminosis occur due to impaired urinary phosphorus excretion and vitamin D activation, leading to secondary hyperparathyroidism and renal osteodystrophy.　These events can lead to severe ectopic calcification in blood vessels and the heart, increasing the risk of cardiovascular disease and death.　In recent years, approximately half of patients undergoing dialysis have diabetes, so it is important to prevent the progression to diabetic nephropathy as one of the three major complications.　Furthermore, it has been reported that hyperphosphatemia increases the risk of developing heart failure and death even when renal function is normal, and blood concentrations of phosphorus and 1，25（OH）2D, the active form of vitamin D, have a circadian rhythm.　Therefore, quantitative, qualitative, and temporal nutritional management of dietary phosphorus during a wide range of life stages from healthy to disease is important for maintaining homeostasis of vitamin D, calcium, and bone metabolism, and for preventing the onset and progression of kidney disease, not only is it useful, but it is also thought to be useful in preventing lifestyle-related diseases such as diabetes and inflammatory diseases from becoming more severe.　In this article, we will discuss vitamin D deficiency/insufficiency in renal disease, its relationship with circadian rhythms, energy and cholesterol metabolism revealed through research on the regulation of vitamin D metabolism, differences in phosphorus sensitivity at life stages.

　Under the titleʻAbout regenerative medicineʼ, I gave a lecture on the basics of regenerative medicine, developments in the field of ophthalmology and regenerative medicine initiatives at the University of Tokushima Hospital to members of the public with an interest in regenerative medicine.

Regenerative medicine refers to medical treatment that uses cells and artificial materials to regenerate damaged functions of biological tissues and organs that have suffered functional impairment or dysfunction.　The aim is to restore the function of organs that are no longer able to fulfil their role due to disease by replenishing cells and tissues.　This new approach makes it possible to treat diseases and injuries that have been difficult to treat with conventional therapies. Regenerative medicine is a rapidly advancing field of medicine with the potential to improve our health and quality of life.

　　In the field of ophthalmology, regenerative medicine research in the cornea and retina is advancing.　Autologous cultured epithelial cell sheets harvested and cultured from the oral mucosa are being transplanted into corneas that have become opaque due to corneal epithelial dysfunction such as ocular pemphigoid.　Clinical trials are also underway to transplant retinal photoreceptor cells and retinal pigment epithelium differentiated from iPS cells.

　　The University of Tokushima Hospital has a regenerative medicine cell conditioning centre with standards approved by the Ministry of Health, Labour and Welfare, which makes it possible to carry out cell conditioning that requires advanced techniques.　With the participation of doctors from the departments of gastroenterology and transplant surgery, plastic surgery, respiratory and collagen medicine, haematology, etc., this system enables cell transplantation therapy and clinical trials, the next generation of cutting-edge medicine, to be carried out.　Researchers and medical professionals are working together towards the development of regenerative medicine while addressing safety and ethical issues.

The advent of iPS cells by Yamanaka et al. has accelerated the clinical application of regenerative medicine.　In the field of retinal diseases in ophthalmology, we conducted the first-in-human transplantation using the autologous iPS cell-derived retinal pigment epithelial cell sheet for age-related macular degeneration in 2014.　Since then, we have been conducting clinical research, aiming for more general treatments, and have now entered the stage of verifying its effectiveness.　For photoreceptor degenerative diseases, we conducted a transplantation of iPS cell-derived retinal organoids containing photoreceptor cells in 2020 and have just confirmed the feasibility and safety of the treatment.　For retinal organoid transplantation, it is also important to determine whether the graft can be functionally integrated into the neural network, and further study is needed on how to evaluate the function as well after transplantation in humans. Furthermore, the pathological condition and environment of the recipient eye are crucial in transplantation therapy, and in the future, it will be necessary to consider therapy indications based on the specific disease pathology.

Older people with dementia have different personalities, and it is important to focus on “Humanitude,” which help them live better and to provide care that brings out the patientʼs own abilities.　The aim of this study was to conduct a systematic review of the effectiveness of “Humanitude” care for older people with dementia.　The search was restricted to articles. The search terms were “dementia,” “communication,” “humanitude” and “care.”　The literature extracted from 2014 to 2022 included from Ichushi 66, CiNii 7, and Google Scholar 147 articles.　After screening for research content, 7 references were selected for this literature review.　One quantitative study and seven case studies were included.　All articles demonstrated the potential for Humanitate to have a positive effect on dementia patients and their caregivers.　However, all extracted studies were case reports.　Randomized controlled trials are needed to demonstrate the effectiveness of “Humanitude” for people with dementia and their caregivers.

Iron is the most abundant trace metal and indispensable for the biogenicity of living organisms.　Iron deficiency anemia is often observed in iron-related disorders, and therefore, proactive iron intake is recommended.　In contrast, iron causes oxidative stress by catalyzing the Fenton reaction.　Recent evidence suggests that iron is involved in the pathophysiology of non-iron-accumulating diseases, and the role of iron has been revisited.　In the last three decades, many studies have shown that iron content is associated with diabetes and that high iron intake increases the risk of diabetes onset.　Iron reduction by phlebotomy or iron chelators ameliorates insulin sensitivity and secretion.　Several studies have shown that high iron levels are also associated with obesity.　Therefore, we speculate that iron reduction could exert a favorable effect on obesity.　As expected, iron chelators mitigated obesity by inhibiting inflammatory cytokines and oxidative stress in KKAy mice.　We advocate that “iron stress” is related to iron-dependent inflammation and oxidative stress, and have reported that iron stress is involved in kidney disease, sarcopenia, vascular dysfunction, and so on.　However, non-specific iron reduction always causes iron-deficient adverse effects, such as anemia, and it is difficult to adopt a clinical application.　Macrophage plays a critical role in chronic inflammation including obesity and diabetes.

M1 inflammatory macrophages exhibit an iron-retention phenotype with elevated H-ferritin （FTH） expression.　Mice with macrophage-specific FTH deletion （FTHKO） showed reduced iron concentrations in macrophages, without anemia.　HFD-induced obesity and diabetes were alleviated in FTHKO mice by inhibiting inflammation and oxidative stress in adipose tissue, similar to the effect of systemic iron reduction.　Therefore, macrophages are the main source of iron stress, leading to new therapeutic strategies for controlling the iron levels in macrophages.

In recent years, genome technology has made dramatic progress.　Genome analysis technology began with the development of the Sanger method, and the advent of next-generation sequencers has made it possible to obtain vast amounts of genome information very rapidly. We have always explored for the causative genes of genetic diseases by the latest technologies. Identification of causative genes requires a large number of genome samples.　To date, we have accumulated a huge number of genome samples, including 900 for amyotrophic lateral sclerosis （ALS）, 4，000 for spinocerebellar degeneration （SCD）, 750 for Parkinsonʼs disease, and 2，000 for dystonia.　In order to efficiently identify the causative genes, we have also developed a genetic analysis method using single nucleotide polymorphisms.　Utilizing these techniques, we have identified several causative genes as follows : OPTN and LRP12, causing ALS ; CACNA1G and HSD17B4, causing SCD ; and TWNK, causing Perrault syndrome.　Furthermore, we have contributed to the elucidation of pathogenesis through functional analysis of these causative genes.

Clinical genomics is a medical field that provides services based on genome information.　Clinical genomics is expected to be used not only for the diagnosis of rare diseases, but also for the development of new treatment methods, the selection of better therapeutic drugs, and lifestyle advice tailored to the individualʼs constitution.　In addition, genomic research is being actively conducted not only on conventional monogenetic diseases, but also on polygenic diseases. The demand for clinical genomics is likely to increase further in the future.　Tokushima University Hospital was one of the first hospitals in Japan to engage in clinical genomics, and in December 2022, the Department of Clinical Genetics was renamed the Clinical Genomics Center.　We will continue to expand the functions of the Clinical Genomics Center in preparation for the coming era of personal genome.

Hereditary breast and ovarian cancer syndrome （HBOC） has been reported to account for about 10-15％ of all ovarian cancers, and risk-reducing salpingo-oophorectomy （RRSO） is regarded as the only preventive measure against the risk of such cancers.　It is important for patients with BRCA 1/2 pathogenic variants to undergo RRSO after childbearing, between the ages of 35 to 45, but a multifaceted perspective is needed when considering this procedure, as it may cause physical and psychological problems.　This paper discusses factors that influence decision-making regarding RRSO from three perspectives : demographics, medical history, and psychosociology, with reference to previous studies.　Accurate insight into the background that led to the decision to undergo RRSO is crucial for support.　Above all, it is essential to utilize such insight in healthcare as vital information to prevent death from breast or ovarian cancer among HBOC patients.

For local government hospitals in sparsely populated areas, access to emergency and specialized medical care is essential for the wellbeing of local residents.　However, Tokushima Prefectural Kaifu Hospital has grappled with numerous crises in the past, stemming from a chronic shortage of doctors.　Due to the inherent challenges and constraints associated with traditional face-to-face medical treatment, where doctors directly provide medical care, it becomes challenging to ensure the sustainability of emergency and specialized medical care with limited staffing. To address this issue, we are opting for a paradigm shift in medical care driven by digital technology, often referred to as Digital Transformation （DX）.　At our hospital, we introduced a remote emergency medical treatment system for emergency medical care in 2013 and for remote outpatient treatment in 2018 as part of medical DX.　The former is a system that transmits medical images taken at a hospital to a smartphone or tablet to support on-call doctors and foster collaboration between hospitals.　Under remote outpatient treatment, specialists from remote medical institutions deliver medical care to patients visiting our hospital; this service has been harnessing 5G connectivity in recent years.　By embracing medical DX, we not only ensured the quality of medical care but also reduced the mental and physical strain on doctors and patients.　This enabled medical institutions in depopulated areas to provide sustainable emergency and specialized medical care.　If implemented, these measures may contribute toward rectifying the medical disparities between urban and depopulated areas.

　A female patient in her 60s who was diagnosed with rheumatoid arthritis has been treated with methotrexate for 12 years, and iguratimod for 7 years.　She was referred to our department because of the liver injury and ascites.　In laboratory data, PT-INR was 1．26 （63．2%）, serum albumin was 1．9g/dL, M2BPGi was 4．97COI, indicating liver fibrosis and decreased hepatic synthesis ability.　An abdominal ultrasonography （AUS） showed ascites, and liver stiffness value was 12．7kPa using shear wave elastography, indicating F4 fibrosis in new Inuyama classification.　Histopathological examination of liver biopsy showed A2 chronic active hepatitis and F2-3 fibrosis.　In Azan staining, it showed luminal stenosis of central vein.　Therefore, she was diagnosed with hepatic sinusoidal obstruction syndrome.　We discontinued the administration of methotrexate and iguratimod, and then liver function was gradually improved.　Hepatic sinusoidal obstruction syndrome is often associated with hematopoietic stem cell transplantation, chemotherapy drugs such as oxaliplatin, and radiation therapy.　In our knowledge, this is the first report of the case with hepatic sinusoidal obstruction syndrome, which occurred during the course of rheumatoid arthritis treatment.