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Dr. Nishiyama's Columns

1. RADIATION INJURY  Rainbow No. : No. 315 (September/October 11)

A record-breaking earthquake and subsequent tsunami hit the north-eastern region of the Japanese archipelago. Even a nuclear power plant, once believed to be invulnerable, was demolished by this apocalyptic natural disaster. To our great dismay, the restoration of the damaged plant has thus far shown little progress.

The exposure of the human body to radioactivity should be as small as possible, and as in short time as possible considering its cumulative harmful effects.

We are, however, incessantly exposed to a small dose of radiation both natural as well as man-made for industrial or medical purposes. Ordinary people are exposed to 3 milisieverts (mili-Sv) of natural radiation yearly, and another 3 mili-Sv per year by medical procedures. With appropriate caution, medical examinations with some sort of radiation can be conducted safely.

If a person’s body is exposed all at once to a great dose of radiation, namely 6 Sieverts (Sv)—1000 times more than what an ordinary person is exposed per year—he cannot survive.

On the other hand, even higher dose of radiation may be tolerated if the radiation is limited to a small area of the body in small doses, and is scheduled in periodic cycles, just like in the case of cancer therapy.

The current concern is focused on the effect of rather small dose of radiation, which has been evident in the area not so distant from the destroyed nuclear power plant. Similar cases in the past include the detonation of the Hiroshima-Nagasaki atomic bombs, the accidents at Three Mile Island and Chernobyl have been carefully analyzed world-wide.

Yet it still remains difficult to predict the long-term effect of low-dose radiation. Unfortunately, however, each comment or report on these past disasters differs greatly depending on the commentator’s view-point or political motivation. We often hear that many case of infant thyroid cancer have been found in the Chernobyl area. On the other hand, only a slightly elevated incidence of cancer or birth defects was reported in Japan after the nuclear attack at the end of the World War II.

The risk of developing cancer, a congenital anomaly, or miscellaneous diseases in a long-term observation may surely exist, yet may not be so great as ordinary people fear. If the officially reported intensity of radiation in one area is trustworthy, such as in the level of micro Sieverts, the majority of residents should be able to enjoy peaceful and productive lives.

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2. The "Accreditation System of Hospitals"
Rainbow No. : No. 309 (September/October 10)

Q. Whenever I or my family members are sick, I am at a loss as to which hospital to go or which doctor to see.
A. The objective evaluation of skills or the quality of care and their accreditation is difficult. Why? In some cases, only the outstanding technique of a surgeon counts, while in other cases, the comprehensive credibility of the hospital including the efficiency of the nursing team, etc. is of utmost significance. At present, the number of cases of specific surgery is considered as the best proof of an excellent hospital. However, a famous, experienced doctor is sometimes found in a small but specialized hospital with a modest number of cases. The good results of treatments are undoubtedly the most important indicators. However, some hospitals tend to collect “easy cases” but avoid risky ones. Thus, it is too difficult to simply apply a rating system in the medical field.

Q. Recently, we often see the title “Approved by the Japan Council for Quality Health Care” in the signboards or ads of hospitals. What does this title mean?
A. The “Japan Council for Quality Health Care” was instituted for authorizing the evaluation and accreditation of medical care. To be successfully approved, the hospital has to clear all of the strict conditions including having a “hospital philosophy,” as well as keeping strict manuals and guidelines of all phases of medical practice and administration. For example, treatment procedures consist of planning, implementation, evaluation and assessments, and each step needs a meeting and discussion among pertinent members, or permission and decisions from a variety of committees. These are inevitable process for the medical practice, therefore qualified staffs are usually trained to perform these tasks in a moment and almost unconsciously. Most hospitals are, and were, however, good reliable hospitals even without such approval, and so you need not put too much importance to such a title when selecting a hospital.

Q. You say, to assess the level of medical services at a hospital is indeed difficult?
A. It is like putting the cart before the horse if doctors or nurses are obliged to give precedence to observing formalities, while being negligent or absent-minded of keeping the safety or protecting the patients. It is undeniable that some accreditation system for the medical services is necessary; however, strict compliance to the excessively bureaucratic procedures and formalities will cause people stress. The psychological pitfall of ordinary personnel should not be overlooked: satisfactory medical care will be provided in a peaceful work-place rather than in a stress-stricken environment. I expect the Japanese medical society to improve the rating system to be more reliable, which will enable everyone to find compassionate medical care by a good doctor or gentle nurses.

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3. AIDS and HIV Infection
Rainbow No. : No. 306 (April 10)

For the past two decades, people have been afraid of AIDS as a fatal condition, or at least one that may devastate their normal lives. AIDS (acquired immunodeficiency syndrome) is known as a late consequence of HIV (human immunodeficiency virus) infection. HIV belongs to a group of retroviruses which rarely cause acute symptoms. Instead, however, the virus replicates in special kinds of lymphocyte cells called CD4 or other immunocompetent cells (those able to develop an immune response), and eventually renders the victim in a state without resistance to infections and malignancies. Without both cellular and humoral immunity, one develops a variety of viral, bacterial or protozoal infections or a wide spectrum of cancers. Despite extensive studies world-wide, an effective taskforce to eliminate the infectious viruses has thus far not been established. Now, an estimated 33 million people in the world have been infected with this virus. Worse still, human-to-human infection spreads with each passing day.

Until only recently, especially in industrialized countries, HIV infection was thought to be a by-product of certain subcultures, such as homosexuality or drug-use. There are, however, cases among people of ordinary sense and education where a person unknowingly becomes infected with HIV via blood transfusion or biological medicines made from human blood. The latter was frequently used to cure the critical bleeding tendency of hemophilia. Today, unusual development of certain kinds of cancers such as Kaposi’s sarcoma or infections such as pneumocystis carinii pneumonia, or even the reiteration of frequently encountered infections are thought to be suspicious signs of some stage of AIDS or HIV infection.

HIV can spread directly from a mother to a baby during delivery or via milk by breastfeeding. In developed countries, careful maneuvers protect the baby from infection, while in developing countries such as those in central Africa, this is hardly affordable. Thus, HIV infection takes place as soon as a baby is born, and a hundred times as many babies as those have started the treatment are newly infected with this virus. Extreme poverty due to natural disasters, ethnic conflicts etc. ―all such calamities exclude poor people from access to modern medical procedures that protect children. If the spread of new infection is unabated, what will become of the African people?

HIV is thought to have its origin in the species of apes. Does a gorilla infected with this virus develop AIDS? Experts are skeptical about this. Then, why are we humans so susceptible to AIDS? The genetic difference may explain a different manifestation of a viral infection. In the past, the indigenous people in the African jungle fed on the uncooked meat of apes. Even today, some people follow that life-style. With time, the virus changed as to be infectious among humans.

The clinical course of this virus infection is rather slow and insidious. The asymptomatic and apparently healthy stage of HIV infection, called a “window” lasts for about ten years. When viral replication overgrows the replenishment of lymphocytes CD4, the manifestation of AIDS becomes overt. For this reason, CD4 count is crucial to assess the stage of AIDS and the prognosis of the patient. Night sweat or weight loss after sexual contact with a possibly HIV-infected partner strongly suggest infection. In Japan, serological tests for possible HIV infection are conducted for free and anonymously at nearby health offices. Usually, a recent HIV infection causes no specific symptoms. Antibodies against certain components of the virus will turn positive six weeks after infection. In the case that infection is strongly suggested, the patient should not wait for the notice of results, and treatment should be started promptly. The guidelines for medical treatment will be based on the indices of cellular immunity assessed by the CD4 count. The fewer the number of CD4, the further the stage of AIDS is advanced.

Nowadays, thanks largely to the advent of new medicines, the quality of life for a patient with AIDS has been ameliorated remarkably, although these medicines hardly eliminate HIV from the body. Anti-retroviral medicines, which are mainly inhibitors against specific enzymes necessary for viral replication, possibly retard the course of AIDS. However, one cannot count on them too much. These medicines may sometimes suddenly cease to be effective, or may have intolerable adverse effects. The mainstay of treatment has still been limited as palliative ones which are aimed to control the opportunistic infections of other pathogens, or to improve nutritional conditions to get a better quality of life and to extend one’s life. In contrast to cases of other viral infections, a vaccine has not yet successfully developed because of the rapid serological mutation of the HIV. Furthermore, those medicines or agents are still so expensive that even patients in wealthy countries, let alone in poor ones, cannot afford them for long-term use.

The best and only way not to get infected with HIV is to avoid risky sexual contact. The use of condoms highly reduces the chance of infection for both partners at a relatively low cost. Public health education should be reinforced, especially for young people, to teach the fear of HIV infection and AIDS. We in developed countries can help poor children with small donations. Just as in the case of global warming, AIDS is really a huge, formidable problem, yet its defeat ultimately rests on individual understanding and prevention efforts.

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4. Infectious Diseases Passed from the Pets
Rainbow No. : No. 296 (June 09)

Pets are more than family members, and they give us great comfort in our lives. However, mistreatment or improper maintenance of our pets sometimes ensues unexpected infections of a variety of diseases caused by bacteria, viruses or protozoal germs which are common in both humans and animals. The chance of getting infected by pets is rather small compared to other ways, but the above facts should always be kept in our minds. Infants, pregnant women, or immunocompromised persons are particularly susceptible to pet-derived infectious diseases.

Some diseases are directly transmissible to humans from pets. In most cases, however, wild animals or birds with fleas or ticks in their skins, which are transferred to our pets, are perhaps a greater source of pathogens responsible for passing diseases. For this reason, wild animals should not be kept at home, no matter how cute and friendly they are. Not only sick animals or birds, but also healthy ones may pass diseases to humans. Skins of pets such as puppies, kittens, and chicks, may be contaminated with their own excrements even though they look clean. In particular, feces contain various kinds of disease-causing agents such as bacteria and parasite eggs. Also, the moist skins of snakes, frogs, lizards or even fish harbour salmonella germs. For this reason, after you touch and care for your pets, you should wash your hands and fingers thoroughly under running water. Teach children that pets always carry diseases, and that hand-washing is the best way to prevent them.

Many of these pet-transmitted diseases initially resemble a mild cold or gastroenteritis. However, protracted course of morbidity or emergence of lesions in the remote organs may cause physicians to panic. Let the physician know at first that you came in contact with animals. Then, the diagnosis can be made earlier, and subsequent treatment will be more precise. The diagnosis can be made either by direct isolation of a pathogen or by serological tests.

Generally speaking, feces of mammals contain campylobacter or salmonella, which cause gastroenteritis in humans. Cryptosporidium, a kind of protozoa, also causes an outbreak of severe enteritis via contaminated drinking water. Droppings from birds such as pigeons have cryptococcus germs, a kind of fungus, which cause meningitis. Apparently healthy parrots or parakeets, let alone sick ones, contain chlamydia in their excrements, which sometimes cause severe respiratory diseases. As mentioned earlier, snakes, turtles, frogs, and lizards harbor salmonella in their wet skins.

Let me focus on a few important diseases.

Rabies: While rabies has been eradicated in Japan, some illegally imported pets may have already been infected with this virus. Symptoms of this disease may appear after a long incubation period. A tourist who had been bitten by an animal overseas was reported to have developed overt symptoms of rabies after returning to Japan. Rabies is a virus-induced encephalitis which cannot be cured even by intensive care and immunoglobulin. We should be more alert that animal bites sometimes result in death! If you are traveling abroad, you should receive an immunization. Even in developed countries, wild animals such as raccoons—although they look cute and friendly—may have beeen infected with rabies. Any wounds resulting from animal-bites should be washed thoroughly with soap and running water, and that animal must also be checked for possible infection of rabies. Rabies vaccination is compulsory for all dog-owners, world wide.

Toxoplasmosis: The major source of toxoplasma infection is the feces of cats. Skin of a cat may be contaminated with its excretions which contain the eggs of toxoplasma, the protozoal germ. The pathogens will be passed to your hands or fingers, and eventually be ingested unintentionally. Stray cats, which are ubiquitous in Japan, love to hide their feces in the sand-box of a children’s playground. The sand, with which the children play, contains a huge number of toxoplasma pathogen that poses a risk of infection. Cats should be strictly separated from the playground by nets. Toxoplasmosis resembles the infectious mononucleosis, which is a common viral infection, and is usually cured in several months. However, in the case of pregnant women, particularly those with low immunity, the disease may result in stillbirths or fetal defects. Congenital toxoplasmosis results in brain damage or blindness. A serological test for toxoplasma antibody is recommended for young females.

Turalemia: A large number of ticks lurking in the skins of wild rabbits or mice carry tularemia. Those bitten by these ticks suffer sudden headache, fever, and ulceration of the bitten area. Although some antibiotics are effective for this bacteria-induced disease, aerosols containing this pathogen cause pneumonia through airborne transmission between humans. For this reason, tularemia has been defined as one of the tools for bioterrorism.

Q-Fever: Dry feces of pets or livestock, even those of healthy ones, contain huge volumes of coxiella, a kind of rickettsia. This pathogen easily flies into the air to cause airborne infection to humans, from a mild flu to severe pneumonia or endocarditis. In many cases, the disease passed from pets such as prairie dogs cause prolonged fatigue and decreased motivation, but few people suspect that one is suffering from an infection transmitted from one’s own pet.

Psittacosis: Chlamydia in the feces of sick or healthy birds sometimes causes severe pneumonia or heart disease, especially in elderly people with a weakened immune system.

Cat Scratch Disease: After getting scratched by a cat, your lymph nodes in the neck or armpits will swell. Extermination of fleas in cats is helpful for preventing this disease. Pasteurellosis: The wounds of dog or cat bites become worse, and cause a fever or swelling of the lymph nodes. If people with chronic lung conditions inhale this bacteria contained in the feces of pets, they may develop severe pneumonia.

Other pet-derived diseases include brucellosis, a mild but prolonged sickness, and many parasiteinduced diseases that cause various symptoms.

To enjoy life with pets, we have to keep our pets in good sanitary conditions. At the same time, we should not give food using our mouths or give mouth-to-mouth kisses, and should not share dishes and beds with pets. We have to remind ourselves that pets are still animals. But can placing certain restrictions such above be considered as love?

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5. Complementary and Alternative Medicine (CAM)
Rainbow No. : No. 292 (February 09)

Modern medicine which developed mainly in western countries has been a great boon to mankind, and is based on the combination of cytopatholgy and molecular biology. Only those methods that are statistically proven to be effective and safe are applied in clinical settings, and that is why they are considered very valuable and reliable.

However, even with such modern medicine, it is far from being a panacea and is leaving some diseases incurable. Take cancer for example. Though the standard medicine aims to eradicate cancer cells by surgery, radiation or by chemotherapy—often accompanying some pains—there are no guarantees for its recovery. Moreover, physicians and nurses often look at only the physical phenomena of the disease and rarely take time to concern the spiritual and psychological aspects of the patients.

Dissatisfied with this grim aspect of contemporary medicine, many people today are apt to seek alternative options such as turning to a variety of exotic therapeutics which are not conducted by physicians. Since ancient times, unique remedial procedures have been carried out in Arabian countries, India, China and many other parts of the world and amongst many ethnic groups; some of them have been studied in earnest, while others remain in the realm of folk beliefs. In particular, traditional Chinese medicine, acupuncture or Ayuruveda in India and homeopathy in the United States have been systematically organized to some extent. As their knowledge and techniques became standardized and their education for the practitioners became well established, numerous people, especially the intellectuals in western countries have come to show some level of support. There are also folksy herbal therapies, dietary supplements, manipulative body therapies like chiropractic treatment and spiritual therapies (as demonstrated by one's faith in a religion or cult) that claim therapeutic effects respectively and that are backed with empirical evidences. They are altogether encompassed into the term: "Complementary and Alternative Medicine (CAM)"—in most cases, people practice these procedures in conjunction with modern medicine.

Why do these "mystic" medical treatments draw our attention today? One of the main reasons may be the limitations of aforementioned conventional medicine. At the same time, people today are a lot more concerned with mind-body interaction than in the past. For example, it has long been believed that a cheerful laugh makes a person both mentally and physically sound. As a matter of fact, the latest research in science proves that a "pleasant-feeling" is positively-correlated with a person’s immunity; hence, his prevention of illnesses. Although most people do not rely solely on these less-approved, medical techniques, they often find some benefits in them. However, only a few have thus far elucidated whether those curative powers are real or simply the nature of a placebo effect, leaving sporadic, success stories of CAM as just anecdotes. But whatever they may be, something curative ought to be evaluated at least as a palliative therapy. Similar to one's firm persuasion in a religion, scientific approaches to verify the procedures for CAM hardly seem to be applicable, for they are more or less the medicine of the spiritual world.

Meanwhile, skeptics of CAM argue that its procedures are lacking credible scientific theories in that its effectiveness and its short-term and long-term adverse effects are not clearly assessed by statistical analyses. Even if that is the case, if there is CAM that promises one’s mental serenity and physical fitness by minimally invasive methods, then it doesn’t hurt to give it a try, right? Although the stance on CAM is different from country to country, many governments or medical institutes are now beginning to devote a huge budget for its research and education, rather than neglecting it as "another superstition".

In the near future, contemporary, western medicine and old oriental or other traditional medicine may possibly be integrated into a more effective, harmless, and spirit-oriented ones. The phrase "conquering the disease" does not necessarily mean the disappearance of one’s pathological condition, but instead, the rendering of his body to function optimally while enriching his spirit.

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6. How to Detect Cancer in Early Stage
Rainbow No. : No. 289 (November 08)

Much interest has been paid on cancers which always rank the top cause of human mortality, and many researches have been conducted on their causes to this day. However, the more they are profoundly studied, the more their mechanisms remain difficult to understand. At the same time, the progress of cancer diagnosis and treatment are so remarkable that we sometimes bear an illusion that people no longer die of such diseases.

In any case, early cancer detection is still the key to increasing a patient’s survivability, but because their specific symptoms, signs, and abnormal values (even with blood tests) are not shown in their early stages, it is not an exaggeration to say that they can only be detected by chance.

Here lies the significance of a regular health check-up: if there is a single test that can detect any kind of cancer, then we can avoid many unnecessary examinations. So far, to our regret, there hasn’t been such a convenient method, because even a blood test for specific tumor markers will not turn positive until they have developed to a certain size. Though positron-emission tomography (PET) commands a great expectation as a versatile tool for detecting cancer—in which a tiny lesion can be delineated in a person’s body without causing much pain—the result often turns ‘negative’, for reasons yet to be understood, on major malignancies such as stomach or colon cancer.

For this reason, it is practical to examine for cancers that are common or those occurring in greatest frequency. In Japan, these include lung, stomach and colon cancers in both sexes and that of mammary gland as well as uterine cervix in females. The method of examination will depend on their site, and an expensive one does not always assure the best procedure.

The image diagnosis has still been the mainstay of cancer detection, and an ongoing development in this field is quite remarkable. In an ascending order of its cost, they are: plain X-ray picture, ultrasound sonography (echography), endoscopies, computed axial tomography (CAT), magnetic resonance imaging (MRI), and positron-emission tomography (PET). Both CAT and PET use radiation in their methods, and their frequent use is sometimes criticized for causing adverse effects of radiation-induced cancerogenesis on patients. Nevertheless, their clear and convincing images for the location of tumors often outweigh those negative sides.

Of the above procedures, the ultrasound sonography is not only the least expensive and harmless, but also exhibits a great advantage in detecting cancer in deep and superficial organs such as liver, gall bladder, pancreas, urinary tracts, thyroid and mammary glands and gynecological organs. However, its disadvantage is that the sound waves do not penetrate as smoothly for an obese person due to the extra amount of fat in the body; thus, concrete images are not produced for a clear observation.

Sometimes, an X-ray picture fails to show the lung tumor in its early stage, in which case, CAT is used to detect the lesion. As for MRI, it is suited for displaying tumors in the bones, brain or pelvic cavity: an area where the respiratory movement least interferes with the image. For examining cancers in digestive tracts, endoscopies are the most appropriate means, and biopsy for pathological examinations is also conducted simultaneously. In the past, swallowing an endoscope was torturous for patients, but ever since the advent of a small-sized, nasal gastroscope, the examination has become much tolerable.

In Japan, sophisticated medical instruments such as endoscopes are commonly used even in a small town, and they are well known as a Japanese monopoly. Of course, making a correct diagnosis requires the access to appreciable images and processionals who can interpret them. Nowadays, digitalized images can be sent to an expert overseas via the Internet, and a pertinent advice for the diagnosis and the treatment can be fed back expeditiously.

Interestingly, some tumors grow rapidly whereas some develop only slowly. Roughly speaking, the former group includes lung, pancreas, and esophagus cancers or some hematological malignancies, and the latter group contains stomach or colon cancer; however, there are many exceptions. In most cases, however, rapidly growing tumors are accompanied with specific symptoms such as pain, cough, palpable mass, fever or bleeding. Today, appropriate examinations are available for such cases.

Aside from the people with high probability of developing cancer such as those with hepatitis virus infection, healthy people are advised to have a regular check-up with the following schedule. (Please note that this is neither authorized by the academia nor is statistically proven, but is instead based on the long experience of the author in this field, who believes that it’s a practical measure, if not the best.)

Firstly, a yearly examination of chest X-ray and abdominal echography are recommended. Next, endoscopies of upper and lower digestive tracts once every few years and ultrasound studies of mammary and thyroid glands as well as gynecological organs are optional within the same time frame. Tumor markers are also recommended every year in combination with an annual health check-up. Considering their cost and limitations, however, PET studies should be conducted once every three years as a source of supplementary information.

What! Are you telling me that you have cancer even after all that testing? Well, that will probably be because you are one of the selected persons of goodwill who are called by God to join him in his world.

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7. What went amiss with medical care in Japan?
Rainbow No. : No. 285 (July 08)

Whenever we hear the siren of an ambulance, we hope for a prompt and appropriate care for the acutely morbid or injured individual. Moreover, with new medicines, modern techniques, as well as sophisticated instruments all coming into practice day by day, we place ever a greater expectation on their benefits, whilst at the same time, believing that medical practitioners' careers are for the most part, driven by their heart to serve the people (i.e. less on the handsome payoff itself). To our disappointment however, we often hear news in which emergency patients are bounced from one hospital to the next. What is going on here? In essence, this unusual trend has been caused by the combination of two contradictory factors: one is the economic impact brought on by the cutback of the medical insurance system, and the other is the public's increasing demand for an impeccable medical service.

If the cost of the medical care surpasses the actual amount funneled by the public insurance or the government, the hospitals will have to recoup this difference by cutting those services which are in deficit; otherwise, they will go bankrupt. In particular, these include the emergency medicine and nursing care for the elderly that require a large number of staff especially during the holidays and evening shifts. The economic impact itself can be alleviated either by reducing the coverage of the insurance, or by lowering the quality of the care. Should that be the case, however, there will certainly be some growing frustration amongst those people who appreciated the benefits at a relatively low cost. On the other hand, should the quality of the medical care become even more refined than today, who will shoulder that skyrocketing cost? Hence, these two contradictory demands ultimately breed economic hardship in the medical arena and result in the absence of providing even a modest care for the patients. In other words, the sublime ideal can never flourish in the harsh climate of the reality.

In addition, you might have come across the term, "unnecessary medical care", but what exactly does this mean? For instance, if the provisions of medical resources for the elders (with whom we can no longer expect any contributions to the society) are deemed as "unnecessary", then we can achieve extra savings for other causes. Although, no government can recklessly take such a cruel and immoral approach, in reality, there are existing policies in Japan which are implicitly pushing this idea via cutting down the defrayment to hospitals and thus deteriorating their status quo.

Even if this is the reality, shouldn’t there be at least some hospitals of good will that are operating in spite of this financial challenge? There were, but many of them have gradually died out for they failed to establish the infallible medical skills, hardware, amenities, hospitality, etc. demanded by the public at large. On top of this, the media and the police are ever on a close watch to seek signs of suspicious faults or imperfect treatments at hospitals. Thus, a humane intention to cure the patients may now possibly end in lawsuits, or better yet, the stigma of committing a crime if the results are unsatisfactory for the patients. For this reason, many hospitals have now become sensitive to deal with cases which involve possible public disputes; if they want to protect their employees and avoid lawsuits or bankruptcy, the safest measure is to not lift a finger, whereas raising a scalpel entails a great risk.

No matter how laborious it may be, working on the patients' bedside is looked upon as doing nothing, unless it is precisely shown in the written form. To exaggerate, completing a bulk of documents (i.e. care-planning, daily assessment, infection-control, etc.) is the only criterion for a "good care" at hospitals even if the patients are left unattended. Moreover, solid policies implemented by the government often contradict with the common, medical knowledge of professionals, despite the fact that the patients' responsibilities always lie on the hospitals' side. With all these combined, the morale of medical staffs has gradually been undermined and good will alone cannot sustain the future of current hospital businesses—what an unfortunate reality! Thus, all the aforementioned troubles and mishaps are not just the matters that fall onto individual medical staff or hospitals, for they are caused by the major misalignment between the economic austerity of the medical system itself and the people's strong desire for a 'super medical care'.

Now that demographic make-up has turned upside down with increased life expectancy for elders and reduced rate for child birth, we need to confront the impasse of medical insurance or pension scheme via the adoption of a new paradigm which captures a rational, sustainable welfare plan.

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8. Norovirus and Gastroenteritis
Rainbow No. : No. 282 (April 08)

The symptoms of vomiting and diarrhea caused by food poisoning can occur even during the winter months. Perhaps most are explained by the manifestation of flu caused by the adeno-virus or influenza virus, and in the latter case, high fever is the most common symptom of all.

The term "Rotavirus" or "Norovirus" have recently come to be known in the general public. Specifically, both have almost the same symptoms which include the combination of frequent vomiting and diarrhea, occasional abdominal pain, and mild to moderate fever. Though the Rotavirus infection is prevalent among young children, Norovirus can occur in all age groups. Let us pursuit with this discussion further.

Norovirus, named after the outbreak in Norwalk, Ohio in 1968, has known to be responsible to the gastroenteritis of all age groups in winter. This virus is sometimes found in bivalve mollusks such as oysters and clams and if the contaminated materials are ingested uncooked, one may develop the above symptoms to various degrees. Since the feces or vomitus from the patient are the main sources of infection, an infected person could potentially cause a pandemic in a crowded area. Despite this fear, the incubation period for the infection is as short as one or two days. For ordinary healthy individuals, the disease is self-limiting; thus, they will recover within three to four days without taking any medications. Debilitated patients, infants, and aged people, however, sometimes enter a grave condition due to the development of a secondary bacterial infection or due to the inadequate correction of fluid balance in their body. In such event, an intake of plenty of water little at a time is recommended for preventing the further progression of dehydration; hence, stopping the worsening of the disease.

Moreover, adding a small amount of glucose and salt (never try them in high concentration) has been believed to facilitate the absorption of water from the intestinal mucosa. In fact, drinking 'sports drinks' is the most convenient and effective treatment for dehydration at home. In extreme cases, however, intravenous infusion of balanced electrolytes solution is available at hospital. In essence, maintaining a balanced body fluid is an effective measure to tackle this virus. In fact, ineffective dehydration treatments often account for the high infant mortality in developing countries, for aggravated dehydration shuts the proper functioning of body organs leading to fatal consequences.

Having said this, we must have some precautionary measures which we could apply at home. Since the virus is heat-labile, food should be cooked well before eating and kitchenware should be heat-disinfected and dried. In addition, clothes or bed linens contaminated with the virus, let alone feces or vomitus, must be sterilized thoroughly with chlorine-based disinfectants (i.e. alcohol or detergents are proven to be ineffective to this virus), and you should wear disposable plastic gloves and a surgical mask when doing so. Furthermore, virus particles can fly in the air from the dried excretions. Though it can only replicate in living cells, we should always be cautious that the virus is ubiquitous and could enter into our body from our mouth by a chance. For this reason, the bathrooms, tables, chairs, handrails of stairways, etc. at nursing homes are all wiped with a diluted bleaching agent. Although this requires extra work at the facility, it is an indispensable safeguard against the outbreak of the virus.

Even at a reputable seafood restaurants that offer fresh oysters, they cannot fully guarantee that their dishes are always virusfree. Whether you engage in a seasonal delicacy or simply avoid it, in the fear of Norovirus infection, this is a challenging dilemma especially for the hungry gourmets.

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9. The Pandemic of New Influenza-A Possible Nightmare
Rainbow No. : No. 280 (February 08)

While much interest has been paid on the global warming, some parts of our planet are experiencing extremely cold days. This paradoxical climate is explained by the change of oceanic current in a large scale. In Kyushu, the temperature is not so low even in winter, but people from higher latitude may feel cold because of the difference in the way houses are structured for heating.

For the past several years, the media has stressed the fear of "new influenza", which refers to the human-to-human transmissible variant of the avian flu. The outbreaks of highly pathogenic bird flu, or H5N1 strain of avian influenza virus, have been recently reported from Asian countries. Some migratory birds are responsible for transporting the virus, but nothing can be done against those that fly around the vast areas of the world.

Its mortality is so remarkable that we all fear whether the virus is also contagious to humans, for viruses can mutate or readily acquire another characteristics over time. So in theory, avian flu can be transmitted to another animal including humans, and once the human-to-human contagion is established, then an epidemic catastrophe in a global scale may occur.

Usually, humans control the outbreak of infectious diseases by using vaccinations or medicines; for this type, however, we have not yet found an effective vaccine, for it can only be produced after the isolation of the virus and determination of the antigen. In other words, massive production of the vaccine is realized only after the first hit of the pandemic, when the virus is readily collectable for analysis. Unfortunately, those patients in the first attack of the virus will have to combat without any vaccine, while those patients in successive outbreaks will be protected to a certain degree by the prepared vaccine.

As for domesticated birds such as chickens, to prevent the further spread of the disease, the affected sites are strictly isolated while the birds are culled. What are some preventive measures for humans? Well, it would be extremely difficult to impose the restriction of personal rights and actions (i.e. suspending poultry farmers' operation license, containing the patients, etc.) especially in civilized countries, and the outbreak and its outcome will likely to cause some unprecedented turmoil and stagnations in both the social and economical activities. Another challenge is deciding who the vaccine receivers should be, in a society where resources are usually scarce and demands are high.

Despite those concerns, anti-influenzal agent has been stocked for the needs of millions of people, and new types are been developed. Early last year, however, more than one hundred cases of abnormal behavior possibly caused by these medicines were reported, and many people became circumspect to use them afterwards. Thus, under the extreme circumstances such as a massive outbreak of a deadly virus, the government and citizens are left to decide respectively, whether to use or abandon the vaccine.

Though we can only pray for such a 'judgement-day' to not occur, long-believed wisdom to avoid the infectious diseases is still practical today. That is, keeping away from crowded places, taking sufficient sleep and nutritions, washing your hands, gargling whenever you came back home, and so forth. Wearing a surgical mask will also help you keep away from catching influenza.

In February, we have the coldest days in the year. By every means you have, protect yourself from the possible outbreak of new influenza and let's welcome the spring days ahead of us.

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10. Overeating and Associated Health Complications
Rainbow No. : No. 278 (December 07)

In winter, people are apt to be reluctant to go out in the cold weather, and eating, drinking and chitchatting in a warm room seem to be the common activities for many. Indeed, eating is one of the biggest pleasures of life, and having this kind of enjoyment is a very fortunate thing. However, “overeating” sometimes leads to health-related problems; thus, I present here, three short talks regarding this matter.

The first one is “gastroenteritis” caused from over-intake of foods or drinks, which are common among younger generation who usually eat or drink more than the older generation. Specifically, a person may suffer from sickness, abdominal pain and/or diarrhea after engaging in heavy eating and drinking. However, thanks to the ameliorated level of life we have today, where the importance of eating seems to have become less than before, such cases are rarely encountered in Japanese hospitals.

Although adults are usually sensible enough to avoid overeating, reckless drinking seems to be the proof of youthfulness. In most cases, a person with an over-inflated stomach will automatically vomit all of his contents, and will recover instantly without having any problems after. However, if a person consumes enough food, the gastric acid contained in the stomach will become diluted, causing various pathogens to proliferate. As a result, food poisoning will likely occur.

The second one is habitual overeating, which may lead to metabolic syndrome discussed in the previous issue. Specifically, an obese person with a small stomach will actively send his gastric contents in succession. In such case, the stomach is hardly filled up and hunger will not be readily satisfied. For this reason, a fat person (with a small stomach) is likely to eat a lot and is prone to become obese. On the contrary, a skinny person has a large stomach dangling in his lower abdomen. Thus, contents will remain longer in the stomach, and even a partial inflation of the stomach will send a signal to the brain to not to eat anymore. As a result, thin people do not eat much and can hardly gain weight.

In recent years, the so-called healthy foods have been introduced in the market. So far, they seemed to be tantamount to the poor or hardly palatable food types both in quantity and quality, and this has been the chief reason behind people’s inconsistent dietary regimen at home or in the hospital. One day, I hope somebody will create a variety of tasty, healthy foods, so as to help people suffering from matabolic syndrome.

The third subject is “eating disorder”, which is the most difficult of the three to solve, for even an educated person may encounter this problem. Excessive eating and its counter-extreme, anorexia, and fatal emaciation, are different types of eating disorder, which are dealt with similar principle. They require the assistance of a specially trained team of medical staffs and mental counselors, who can rescue them from their deep, self -made psychological hell. Only through this, will they gradually become detached from excessive eating or attached to proper diet, and enjoy a moderate, healthy lifestyle.

The winter in Japan brings much warmth among friends and families who sit in the Kotatu and chat while eating sweet oranges. Let us remind ourselves, however, that there are nearly hundreds of millions of people without adequate food supplies. From this point, it is important for us to value food and not waste them.

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Rainbow No. : No. 277 (November 07)

The term "Metabolic Syndrome" has not rested as a fad word among medical professionals, but it has also been widely recognized among middle-aged males in Japan. Its definition has been outlined in the previous issue of RAINBOW in the context of a physical examination programme provided by the Fukuoka Health Promotion Center.

Although the diagnostic criteria for the metabolic syndrome may depend according to schools or racial groups, obesity and subsequent resistance to insulin are the key factors leading to the illness. Specifically, if three of more of the following unhealthy signs are found in a person, his or her chance of getting a metabolic syndrome, eventual heart attack, or brain stroke would be higher than the average. Namely, they are obesity (accumulated visceral fat tissue), high blood pressure, elevated blood glucose level (insulin resistance and Type II diabetes mellitus), and high value of "bad" cholesterol (high triglyceride) in the serum. It is said that, in Japan alone, about twenty million people are at this risk, and the combination including diabetes is said to be the worst of all.

Without looking at their laboratory data, those having metabolic syndrome look rather healthier than a normal person; this is the reason why they are hardly serious about their own health risks. When Asians or Hispanics become obese, they are more likely to have metabolic syndrome than Caucasians probably due to certain genetic differences. In addition, Japan’s economic development has brought excessive calorie intakes and sedentary works among the citizens, and these in turn have resulted in unprecedented health problems such as metabolic syndrome. As everybody knows, a change in life style is crucial for the prevention and treatment of this syndrome, yet ensuring one’s health in a complex modern society is harder than it seems.

Nevertheless, let us start with anything that could contribute to a person’s weight loss; for example, engaging in a balanced diet, walking exercise, etc. An encouraging phrase was found in the journal TIME, p40, Sept. 17, 2007: "Modest amount of weight loss can benefit overall health, even if the loss does not feel or look like much." So, it is important to steadily become healthy, while not giving up or rushing to lose your weight. By doing so, you should be able to enjoy the rest of your life in an optimal health.

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12. Shake off your summer lethargy
Rainbow No. : No. 275 (September 07)

During a hot summer day, even the lion, the king of the jungle, lazily sleeps under the shade of a tree. In South-Western Asia, an unusual silence veils the jungle in the afternoon, as the birds and the insects cease to be active under the scorching heat.

The Japanese summers are intolerable due to the combination of the heat and humidity. Nowadays, we can escape indoors to airconditioned havens, but that in turn has made us less tolerant to the heat. Anyone can get the dose of summer lethargy, resulting in feeling run-down, a loss of appetite, and so on.

Oftentimes, sleep deprivation worsens these symptoms. This is due to the automatic response of your body to control your body temperature. We tend to move slower because muscles and blood vessels are relaxed to regulate body temperature, and when we sweat we are using up energy. All these symptoms prevent us from conjuring up the energy to be active during the hot summer months.

It is impossible to completely beat summer lethargy, though decent sleep, sufficient intake of fluids, and light meals such as noodles or pasta are recommended. Eels and goya (bitter gourd) have long been consumed by the Japanese to overcome the feeling of lethargy in summer, despite the fact that their effectiveness has not been scientifically proven.

Until half a century ago, it was said that some Japanese men wore minimum clothing like their underwear in the summer. They may hardly have looked presentable, but surely this style they adopted was the ultimate 'cool-biz'. Fortunately, in recent years, a cooler, less formal style has been accepted in offices to conserve energy.

We cannot completely fight off summer lethargy, we have to live with it. Even the king of the jungle submits to nature and takes a rest. The best thing to do is to wait it out till autumn and work extra hard to recover the days we wasted during the unbearably hot summer.

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13. Steer Clear of Heat Stroke!
Rainbow No. : No. 274 (August 07)

On a hot day, you may feel exhausted from the heat, especially after physical exercise under the burning sun. This is caused by excessive heat accumulated in the body, combined with dehydration due to massive sweating. To recover from overheating, you can retreat to some shade, change to more appropriate clothing, and cast your body in a cool breeze. Take plenty water or balanced electrolyte fluids, and you will recover soon. However, do not take alcohol or coffee; although they are also liquids, they will in fact exacerbate dehydration. If you ignore these signs of overheating, the consequence may be disastrous. Excessive perspiration causes profound dehydration of the body, which makes it even more difficult the control body temperature, accelerating the process of organ dysfunction.

Trained athletes or participants in organized activities are rarely at risk for heatstroke, as unlike inexperienced individuals, they are more in-tune with their bodies and proper health management. If overheating is causing illness, muscle cramps, or abnormal sensations or behaviors, you may be about to lose consciousness. Delayed or improper treatment ensues permanent organ damage, or even death.

The elderly, infants, patients on certain medications or the severely handicapped, are more prone to fall into the most severe condition: heat stroke. It can happen even in a shaded place, especially is there is poor ventilation. Unfortunately, each year in Japan, babies are found dead after being left unattended in hot vehicles.

Heat disorders are classified in order of severity from 1) heat syncope due to hypotension, 2) heat cramps due to salt depletion, 3) heat exhaustion; a severe manifestation of the formers, to 4) heat stroke accompanied even by fatal damage in the brain, muscle, and kidneys. Once heat stroke or nearly severe conditions are suspected, cool the body immediately by whatever means; water, ice, fans, etc. Call an ambulance if severe. Prompt intensive care in the ER, including massive intravenous re-hydration, is essential.

When the outside temperature rises up to ordinary body temperature, around 37 C or above, it is advisable to refrain or withdraw from participating in rigorous activities, to avoid this fearful summer incident.

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14. Avoid Food Poisoning This Summer
Rainbow No. : No. 273 (July 07)

While summer activities are in full swing, there also flourishes food poisoning. An acute onset of nausea, vomiting, and diarrhea implicates food poisoning. The ingestion of improperly stored and/or prepared food far broadens the chance of catching food poisoning, but usually after 2 to 3 days you will naturally get better. In addition, an eating or drinking binge may cause the dilution of gastric acid, and that in turn may facilitate the growth of more bacteria in the stomach.

The severity of the illness can range from a self-limited episode to a life-threatening one, depending on the cause as well as the predisposed health condition of the individual. Massive diarrhea may cause not only dehydration, but in some cases dysfunctioning of the kidney as well.
The principal causes of food poisoning are viruses and bacteria that have already contaminated food or water. You can pretty much guess the causative agent based on your symptoms and the time in which it took for the symptoms to show. However, as the number of international travelers and imported foods increases, "foreign" pathogens like protozoa can be encountered much more often in today's world.

If you have any vomiting or diarrhea, take plenty of clear fluids like tea or sports drinks to re-hydrate the body. If you can eat, take only light meals in proper volume. If you have bloody stools and/or fever, that is an ominous sign, and you should go to a hospital immediately. Anti-bacterial medication and painkillers should only be used if necessary, as they can sometimes complicate matters. For self-treatment, it is best just to stick with some over-the-counter antidiarrhoeals agents.

To prevent food poisoning, it is crucial to keep in mind that causative pathogens are ubiquitous; they can be found in food, water, kitchen tools, and even in your own hands. So, wash your hands frequently and use clean and dry kitchenware.

Avoid under-cooked food and untreated water. Even a refrigerator cannot guarantee bacteria-free food.

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15. May Depression
Rainbow No. : No. 271 (May 07)

Despite the bright sunshine and fresh green foliage of May, some people may fall into low spirits. In Japan, this peculiar phenomenon is called, "May Depression".

Students and businessmen begin the new school year and their new careers in April, after a long period of preparing for entrance examinations. Perhaps after the first month, they will become accustomed to their new lives; at the same time, however, they may also feel "burned out" from all the new experiences and their efforts to adjust to them. For some, this new reality may also look something different from their long-harbored dreams. Not to mention, the human body may have difficulty adjusting to the climate change of the month of May. All this in consideration, the body can be greatly affected both physically and psychologically during the month of May.

It may be difficult to adjust to such harsh change, but do what you can to enjoy the beautiful weather in a positive way, in participating out-door activities, or hanging out with friends or a school activity club. A mental health professional will also be able to help you, if necessary.

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16. Hay Fever
Rainbow No. : No. 268 (February 07)

Everyone is looking forward to the coming of spring, with its mild, sunny days, and fresh, blooming flowers.
However, for some, it is also the painful season when the annoying allergy "hay fever" flares up.

What is "hay fever"? Is it different from the common cold?
Hay fever is synonymous to a pollen allergy (Kafunsho in Japanese). It is caused by ultra-sensitivity or a misdirected immune response to allergens in the air. Any biological or chemical substance can be a causative allergen, and the most widely known in Japan is cedar pollen. Unlike the common cold, Kafunsho causes a persistent runny nose combined with itchy eyes, which predominate throughout the season, and may recur each year.

Is there season when I can easily get hay fever in Japan, specifically in Fukuoka?
In the Fukuoka area, many people suffer from sneezing, runny nose, and puffy eyes on warm, dry and windy days in early February through April.

How I can prevent it?
To prevent pollen allergies, avoid contact with the allergen by as many means as possible; refrain from going out on strong days, wear a surgical mask, and close your windows. The use of an air-filter may also be helpful. Change in diet or lifestyle may not necessarily cure hay fever, but keep in mind that historically, when our lives were much simpler and less hygienic, few people suffered from atopic or allergy-related diseases.

What if I catch it?
For mild cases, a variety of anti-allergic medicines are available at pharmacies. However, most cause drowsiness. Corticosteroid nasal sprays are handy, and promptly effective, but should be prescribed by a physician.

I have National Health Insurance. What kind of treatments can I receive from my doctor?
How much does it generally cost?

For your first visit to a clinic, you will most likely pay about 2,000 yen for some tablets and/or nasal spray. More elaborate procedures, like desensitization (allergy-shots), are applied for only severe cases.

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17. What is Influenza?
Rainbow No. : No. 266 (December 06)

Every year in late winter, influenza is prevalent all over Japan. Its symptoms resemble those of a common cold in its severe manifestation, and most cases recover spontaneously within a week with only a bit of bed rest.

How does it differ from the common cold?
Its abrupt onset is remarkable. High fever exceeding 39℃ , muscle pain, headache, general malaise, highly inflamed throat, cough, and sometimes vomiting and diarrhea ensue. Influenza itself or its complication can sometimes result fatally in the aged, infanitile or debilitated.

How can I prevent getting it?
Get sufficient rest and nutrition. Gargling and hand-washing are simple, yet effective methods of prevention. Wearing a mask when going out keeps nasal and throat areas properly moist, and protects from the transmission of the virus from other patients. Immunization is highly effective. The vaccine made from prospective virus strains is available in most clinics and hospitals for about 1,500 - 4,000yen. Double immunization shots given in November to mid-December will be the best time to cover the flu season, but a single shot may also be enough.

What to do, if I catch it?
Bed rest in a warm and well-hydrated room, and sufficient fluid intake is essential. You can use cold medication, but avoid anti-inflammatory pain-killers, except those that contain acetaminophen. If you cannot drink, you may have to receive intravenous hydration Anti-influenzal medicine, "TAMIFULU" is also highly effective, if used at an early stage.

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