In this study, among the aspects of physical disabilities, the actual condition of visceral impairment that lies therein will be explored. Visceral impairment is divided into cardiac disorder, renal disorder, respiratory disorder, bladder or rectal disorder, small-intestine disorder, immunological disorder by HIV, and hepatic disorder.Most of the persons with visceral impairment seem to be able to perform ADL by themselves and seem not to have any problem on the surface. It is important for persons with visceral impairment to actively perform ADL not only so that they can retain the ability to perform ADL and prevent the recurrence of diseases but also so that they can inhibit the aggravation of arteriosclerotic diseases.The number of persons with visceral impairment will increase if the number of persons who do not satisfy the statutory criteria even though they have visceral impairment clinically will be added to the number. Also, the number of persons with visceral impairment is expected to increase due to the advent of a super-aged society. As such, visceral impairment is a significant area that rehabilitation-related professionals have to become knowledgeable about among the parts of rehabilitation medicine.

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呼吸器疾患患者のADL（activities of daily living）評価には，呼吸困難感，酸素飽和度の変化，動作時の呼吸パターンを含んだADL尺度が必要である．日常生活の中で基本的動作であるADLトレーニングを呼吸リハビリテーションの開始時から重症例も含め取り入れていくべきであり，個々の生活環境を把握した生活機能を的確に評価するとともに，継続可能な指導内容，指導方法を検討することが重要である．

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肺気腫患者を，COPD重症度分類により群分けし，ADLの障害状況とその特徴を検討した．Stage II以上で障害が表面化し，Stage IIIでは多くの項目で介助が必要となった．歩行以外に上肢を挙上する動作や腹圧がかかる動作が障害されていた．全群で適切な酸素使用をしていないものが認められた．肺気腫患者のADLの障害に対しStageごとの特徴をふまえた早期からの対応が必要であることが示唆された．

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To assess the possible roles of atrial natriuretic factor (ANF) in the regulation of blood pressure in spontaneously hypertensive rats (SHR), we performed two series of experiments. Firstly, we studied hypotensive, natriuretic and diuretic effects of ANF in pentobarbital-anesthetized adult SHR and age-matched Wistar-Kyoto rats (WKY). A synthetic ANF of 25 amino acid residues was intravenously administered as a bolus in doses of 0.1μg/kg, 1.0μg/kg, 2.5μg/kg and 5.0μg/kg. In SHR, a significant decrease in mean arterial pressure (MAP) was observed at the dose of 1.0μg/kg, and MAP decreased in a dose-dependent manner. On the other hand, in WKY group, the decrease in MAP was observed at the dose of 5.0μg/kg. The diuretic and natriuretic effects of ANF were observed at the dose of 2.5μg/kg in SHR and 5.0μg/kg in WKY. Secondly, we also studied chronic effect of ANF on the development of hypertension in 6-week-old SHR The SHR, on regular diet or given 1% NaCI solution for drinking, were continuously infused into the jugular vein by osmotic minipumps with ANF (150μg/kg/day) or vehicle (physiological saline) as controls for up to 14 days, ANF attenuated transiently the development of hypertension in the sodiumloaded SHR. But the blood pressure returned to control levels by day 5. In SHR on regular diet, ANF did not affect the development of hypertension. In addition, ANF did not induce any significant changes in urine volume, fluid intake, urinary sodium, potassium and kallkrein excretion in SHR on both sodium conditions when compared to those in vehicle-infused SHR. These results indicate that there may be a significant difference in the sensitivity to diuretic, natriuretic and hypotensive actions of ANF between SHR and WKY. Moreover, they suggest that ANF may exert some roles by its vascular effect at the early stage of development of hypertension in SHR on sodium loading.

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心臓リハビリテーション (CR) は, 身体の安全と日常生活への復帰を目標としたPhase I (急性期), 社会復帰を目標としたPhase II (回復期), 社会復帰以後生涯を通じて行われるPhase III (維持期) に分けられる. 最近のPhase II CRでは, 医学的な評価や適切な運動処方と運動療法・薬物療法・食事療法・患者教育・カウンセリングなどをセットにした包括的なプログラムに基づいて行われている. このような取り組みは〈包括的CR〉と呼ばれる. 冠動脈再灌流療法の進歩や急性冠症候群の管理の進歩により, Phase I CRの入院期間が短縮し, 包括的ケアを行うPhase II CRの必要性がますます高まっている. 多要素プログラムを擁する包括的Phase II CRにより, 運動耐容能の増加, 冠動脈硬化・冠循環の改善, 冠危険因子の是正, 生命予後の改善, QOLの改善などめざましい効果が示されている. CRの有効性が認められている循環器疾患には, 心筋梗塞の他にも, 狭心症・冠動脈バイパス術後・心臓弁膜症術後・大動脈瘤手術後, などがある. また, かつてCRの対象外とされてきた高齢者, 心不全, 心臓移植後などに対しても, CRの有効性が明らになっている. 一方Phase III CRの運動療法は, 保健適応外のためもっぱら医療機関以外で行われる. 昨年ジャパンハートクラブが発足し, 心臓リハビリ指導士によるPhase III CRの運動指導が身近なところで気軽に行われるようにする試みも始まった. 医師・患者へのCRの重要性のさらなる啓蒙, CRの専門施設やスタッフの充実, 時間・経済的・内容的に個々の患者に魅力的かつ適切なプログラムの作成など解決すべき課題も多いが, CRは今後ますます重要な分野となると考えられる.

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わが国は世界一の超高齢社会である．超高齢社会では重複障害という新たな課題に直面している．その中でも呼吸器機能障害と心臓機能障害のような内部障害の重複が多い．呼吸リハビリテーションと心臓リハビリテーションで共通して得られる改善効果は，運動耐容能，息切れや易疲労感，QOL，筋血流量の増加，筋肉の酸化代謝能，筋力，自律神経機能，血管内皮機能などがある．重複障害時代のリハビリテーションを担うには，各臓器に特異的な問題とともに，脳・心・肺・骨関節などの臓器連関を考慮することが必要である．

本稿では特に呼吸・循環の重複障害を中心にリハビリテーションの意義と注意点に関して概説した．

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To assess the pathophysiological role of atrial natriuretic polypeptide (ANP) in the regulation of blood pressure, we studied the effect of chronic infusion of synthetic rat-ANP on blood pressure and sodium-water excretion in angiotensin II (A II) -and vasopressin (VP) -infused rats on regular intakes of sodium or on sodium loading with 1% NaCl as a drinking water. When subdepressor dose (150 μg/kg/day) of ANP was infused into the jugular vein by an osmotic minipump (Aizet·) for up to 3 days simultaneously with A II (900 μg/kg/day) infused intraperitoneally by another osmotic minipump, the expected elevation of systolic blood pressure was inhibited little. The antihypertensive effect of this peptide was sustained throughout the experimental period lasting for 3 days in rats on both sodium conditions. It was not accompanied by any changes in body weight, water intake, urine volume and urinary sodium excretion. Additional administration of ANP to rats made hypertensive for 3 days by infusion of A II reduced the blood pressure to a little extent but not to control levels, and the attenuating effect was sustained throughout the experimental period lasting for further 3 days on both sodium conditions. When the same dose of ANP was administered in combination with VP (7.2U/kg/day) for up to 3 days, the expected elevation of systolic blood pressure was completely inhibited. The antihypertensive effect of this peptide was sustained throughout the experimental period in rats on both sodium conditions. It was not accompanied by any changes in body weight, water intake, urine volume and urinary sodium excretions. These results indicate that subdepressor dose of ANP can modulate the hypertension induced by chronic infusion of A II and VP independent of sodium-water metabolism. Therefore it is suggested that ANP may be involved in the regulation of blood pressure via its attenuating effect to A II and VP.

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In the present study, two protocols were used to assess possible role of renal kallikrein-kinin system and sodium balance in the development of hypertension in young spontaneously hypertensive rats (SHR). In the first protocol, daily excretion of urinary kallikrein and systolic blood pressure were measured in the 5-week-old SHRs on regular diet or on sodium loading with 1% NaCl solution for drinking water for up to 3 weeks. In the second protocol, chronic effect of aprotinin, a reversible inhibitor of kallikrein and other serine proteases, on the development of hypertension was studied in young SHRs on regular diet or on sodium loading with 1% NaCl. Subcutaneous injection of aprotinin (100, 000 units/kg/day) or vehicle as controls was continued every 12 hours for up to 2 weeks. Daily systolic blood pressure in the rats was monitored by an indirect tail cuff method. Kallikrein was determined by its kininogenase activity, and the generated kinins were radioimmunologically measured. Urinary kallikrein excretion and renal kallikrein content were significantly increased in SHRs on sodium loading compared to those in SHRs on regular diet. However, chronic sodium loading with 1% NaCl did not affect the progressive development of hypertension in young SHRs. Aprotinin did not affect the development of hypertension in young SHRs on regular diet or on sodium loading, although aprotinin decreased significantly urinary excretion of kallikrein and renal kallikrein content on both conditions.Therefore present results indicate that reduced renal kallikrein-kinin system may not be involved in the development of hypertension in young SHRs on regular diet and on sodium loading. Additionally, it is reconfirmed that sodium is not a main determinant of the progressive development of hypertension in young SHRs.

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The number of the patients requiring rehabilitation has been rapidly increasing. Rehabilitation patients and their families face various troubles and problems in their illness, their functional state, their convalescence, and a wide range of domains including their at-home life and care burden. And rehabilitation staffs must deal with these problems appropriately and take pride in their efforts and strive to provide continuing reliable care. However, most hospitals and rehabilitation centers only have one or at most a few physiatrists. Thus, most physiatrists and co-medical rehabilitation staff have few advisers and are frustrated by the many kinds of problems faced in providing medical service and management. In this lecture, I discuss how to build safety measures, how to write medical records to prevent future troubles, the proper on-site manner, and the 15 traits of a disliked physiatrist. I hope that this lecture can blow away the frustration from the rehabilitation scene and be helpful not only for patients and their families, but also for physiatrists and co-medical rehabilitation staff.

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重複障害の定義と特徴，重複障害を有する心不全患者のリハビリテーション医療の留意点について述べた．重複障害患者も重複障害を有する心不全患者も近年激増しており，リハビリテーション医療でも大きな割合を占めつつある．重複障害を有する心不全患者のリハビリテーション医学・医療を担うには，各臓器に特異的な問題とともに，心・腎・肺・脳・骨関節などの臓器連関を考慮することが必要である．そのためには，リハビリテーション医学・医療従事者は，単にADL評価に留まらずに，循環・腎・呼吸・代謝疾患の病態生理と障害，心電図，呼吸機能検査，血液ガスデータなどの基本的理解や心・腎・肺・脳・骨関節などの臓器連関の理解が必要である．

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