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Japan’s health care system should be the envy of the world. Japan consistently places near the top of the World Health Organization’s overall health rankings, and does so while spending the smallest proportion of its GDP on health care than any member of the G7 (8% in 2004; Canada spent 9.9%), making it perhaps the world’s best health care bargain. This accomplishment can be traced back to the founding of Japan’s national universal insurance health care program in 1961, in which all Japanese could receive equal treatment at any health care facility. This system, however, is in danger of crumbling. In Japan, patients must pay approximately 30% of their medical expenses (including medications) out of their pocket. In 2004, however, this still left the proportion of all health care costs borne by governments at an exceptionally high 81.5% (Canada: 69.8%). Particularly expensive are the country’s drug costs, which make up 18.9% of all medical expenses (Canada: 17.7%). The universal insurance system does exclude certain medical services such as orthodontia and cosmetic surgery; these uninsured services must be paid for out of pocket and are effectively privatized. Japanese law is very strict about the distinction between the provision of insured and uninsured care and prohibits medical institutions from providing both insured and uninsured services as different components of a single series of medical treatments. Since the late 1990’s, however, there has been increasing pressure from the business sector for the government to allow a mixed system in which providers could offer different medical services at the same time, some covered under the public-insurance system and some not. Foreign countries such as the United States have also pressured Japan to introduce market mechanisms and competition to medical care, allowing new insurance plans and medical-service businesses to flourish. In addition, wealthy individuals have expressed a wish to have access to high-level care at the very cutting edge of technology. In 2001, Prime Minister Jun’ichiro Koizumi formed the Council on Fiscal and Economic Policy to bring Japan’s public finances to order, aggressively promoting government-budget reform based on neoliberal principles. With the government’s new emphasis on small government, free-market ideology, market-based incentives and increased privatization, Japan’s social welfare programs faced major changes. Health care was no exception. In 2004, a law was passed allowing private companies to participate in running health care institutions under limited parameters in exceptional cases only. Such involvement was restricted to six areas that were already under the category of uninsured medical services and represented cutting-edge medicine: PET scans and other diagnostic imaging Regenerative medicine Medical genetics Cosmetic surgery In-vitro fertilization Others In 2005, a cosmetic-surgery venture company in Kanagawa Prefecture signed a collaborative contract with a university and became the first such private company to be founded. However, in response to strong opposition by the Japan Medical Association and concerns by the general population, the Ministry of Health, Labour and Welfare took a cautious approach to the growing number of private companies entering the health care sector throughout Japan and issued a number of reservations regarding increased privatization of health care. First, there is a danger that because the medical services required by patients may not be those most profitable to private companies, important medical services may not be made sufficiently available. Second, medical services might no longer be provided in certain geographical regions if service providers withdraw from less profitable areas. Finally, the cost of medical services might increase considerably. In effect, despite the law, private companies are still prevented from forming national chains of health care facilities and the removal of the ban on mixed health care never occurred. This lack of movement has done nothing to change the fact that the Japanese health care system faces increasingly difficult challenges year by year. By 2005, the proportion of the Japanese population older than 65 years old had exceeded 20% and the birth rate sat at its lowest level ever, 1.26. As a result, Japanese society is fast becoming the oldest society in human history, and the long-predicted collapse of the public healthin-surance system is becoming reality. Between 1985 and 2002, the total annual cost of health care in Japan nearly doubled from 16 to 31.1 trillion yen. This funding is split as follows: 51.7% comes from the universal health insurance contributions (shared between employers and employees), 15.3% comes directly from the patient’s pocket, 25.1% is paid for by the national government, and 7.9% is paid for by local governments. Yet with an cost increase of 1 trillion yen (CDN$8.7 billion) per year (after the USA, the highest rate of increase in the world), it is difficult to see where the needed funding will come from. Japan has one of the highest per-capita number of hospitals in the world, with 8.4 hospital beds per 1000 population (Canada: 3.0; USA: 2.8). It is not uncommon for a single physician to run his own hospital, adding to the excess. This is seen as one of the major causes of the unrelenting increase in health care costs. While the government is making an effort to decrease the number of beds that are located in small- and medium-sized hospitals, there is great resistance among the population to dramatic changes in bed distribution, making it necessary for the government to tread carefully. On the other hand, there is a shortage of physicians, with only 2.0 per 1000 population (Canada: 2.1). This problem has been exacerbated in rural areas due the resident-matching system introduced in 2004, which has accelerated the tendency of young doctors to concentrate in urban areas. Rural areas are increasingly likely to lack the necessary doctors and hospitals. Given this state of crisis, calls for the development of private medicine within the areas permitted by law, as well as for increased application of uninsured and mixed medical care, are increasing among government, business, some physicians (approximately 50% of physicians working in hospitals according to a recent survey) and a minority of patients (about 20%). However, the July 2007 House of Councillors election dealt a crushing loss at the polls to the ruling Liberal Democratic Party that had promoted aggressive fiscal reform, including health-care reform. The majority remains opposed to the increased application of market ideology and free-market competition. The election result highlighted the fact that the population wishes to maintain the current universal health-insurance plan, which it perceives as fair and affordable. On November 8, 2007, an individual patient successfully sued the government in the Tokyo District Court by claiming that the government violated his constitutional rights by refusing to allow him to apply his public health insurance to any of his cancer treatment because part of his treatment had included uninsured services. The government had insisted that such prohibited “mixed” treatment relieved it of its duty to pay even for the insurable portion of his treatment. In effect, the court ruled that the government’s suppression of a mixed system was unconstitutional. In response to this ruling, the Japan Medical Association and patient groups expressed concern that the provision of medical care would now depend on patients’ financial status. Other patient groups applauded the decision. The decision is sure to fan the flames of the debate regarding the removal of the blanket ban on mixed health care. Based on recent political events, it is clear that the general population in Japan is in favour of maintaining the present national universal insurance health care system. As a result, the debate on the adoption of increased uninsured or mixed medical care is at a standstill. With the nation in a state of political gridlock, there is little indication that battling political parties will be able to come up with any effective solutions to controlling the rapidly escalating costs that threaten to destroy the health care system voters are so eager to preserve.

症例は38歳男性. 30歳時よりインスリン非依存性糖尿病にて経口血糖降下薬の投与を受けていた. 37歳時,誘因なく水様下痢を発症. 1日6～7回,夜間に多く1年程続き便失禁を伴ったため精査目的にて平成8年9月当科に入院した.糖尿病性下痢症と診断し,ロペラミド,耐性乳酸菌等を投与したが効果なく,コレスチラミン単独投与により,症状の著明な改善が見られた.コレスチラミンは腸管内で胆汁酸と結合し,腸管内における胆汁酸の瀉下作用を抑制するため糖尿病性下痢症に有効と考えられ,本症の治療の1つとして試みる価値があろう.

BACKGROUND Des-γ-carboxy prothrombin (DCP) has been reported to be an important prognostic factor in patients with hepatocellular carcinoma (HCC). Recently, a monoclonal antibody, 19B7, which recognizes the Gla domain of DCP, has been identified. The 19B7 antibody recognizes an epitope different from that recognized by MU-3, which is another antibody against DCP. In this study, the authors investigated the measurement of DCP using the antibodies MU-3 and 19B7, respectively, as a prognostic factor for patients with HCC who had solitary, small tumors and or Child Stage A HCC. METHODS One hundred four patients with HCC who had solitary, small tumors or Child Stage A tumors were enrolled in the study between 1991 and 2001. All patients were treated and were followed for a mean of 3.2 years. The authors analyzed the correlation between the DCP Index (DCP measured by MU-3 and DCP measured by 19B7) and patient prognosis. The patients were classified into 3 groups based on their DCP Index: 1) DCP negative (DCP < 40 milli arbitrary unit (mAU)/mL)); 2) low DCP Index (DCP ≥ 40 mAU/mL; MU-3:19B7 ratio, < 3.0; and 3) high DCP Index (DCP ≥ 40 mAU/mL; MU-3:19B7 ratio, ≥ 3.0). RESULTS The survival rate for patients in the high DCP Index group was lower compared with the survival rate for patients in the DCP-negative group and was significantly lower compared with the survival rate for patients in the low DCP Index group. In a univariate Cox proportional hazards model, the positive factors were high DCP Index and low DCP Index. Among the positive predictive factors that were analyzed using a multivariate Cox proportional hazards model were age (hazard ratio, 3.27; P = 0.006), low DCP Index (hazard ratio, 2.87; P = 0.012), and high DCP Index (hazard ratio, 12.3; P < 0.0001). CONCLUSIONS The prognosis of patients who had a high DCP Index score was poorer compared with patients who had a low DCP Index score and patients who were classified as DCP negative. The authors concluded that the DCP Index is a prognostic indicator for patients with HCC. Cancer 2003;98:2671–7. © 2003 American Cancer Society.

BACKGROUND Hepatitis C virus (HCV) infection is a heterogeneous disease, the natural history of which remains controversial. There is solid evidence that chronic HCV infection is responsible for the occurrence of hepatocellular carcinoma (HCC). The aim of the current cohort study was to determine the rate of the development of HCC from the time of primary HCV infection and to assess the risk factors for the development of HCC in chronic posttransfusion hepatitis C patients. METHODS Four hundred sixty-nine patients with clinically compensated HCV, who had undergone a single blood transfusion comprised the current study cohort. Patients with other risk factors for chronic liver disease were excluded. All patients were referred to the liver center at the National Nagasaki Medical Center between December 1980 and December 1998 and were followed prospectively until the end of the analysis (June 2000). RESULTS Follow-up data were obtained for 445 patients. The mean duration from HCV infection to the end of the observation was 28 years. Fifty-two patients (11.1%) progressed to HCC. The mean duration from the time of blood transfusion to the diagnosis of HCC was 31 years. Multivariate Cox regression analyses revealed age, fibrosis, duration from HCV infection to study entry, and alcohol consumption to be the independent factors affecting the development of HCC. The risk of developing HCC in patients age ≥ 56 years was increased 7.8-fold compared with that in patients age < 56 years. The mean age of patients at the time of HCC diagnosis was 65 years (range, 58–79 years). CONCLUSIONS At the time of diagnosis, 92% of the 52 HCC patients were age > 60 years and 38 of the HCC patients (73%) were in their 60s. There was a significantly negative correlation between the duration from HCV infection to the development of HCC and the age of the patient at the time of infection (correlation coefficient = 0.702; P < 0.0001; Y = 61.1–0.82X), indicating that the age of patients, rather than the duration of HCV infection, is more significant for HCC development in patients with posttransfusion HCV. Moreover, these data may contribute to the design of an optimal follow-up schedule for patients with posttransfusion HCV. Cancer 2002;95:331–9. © 2002 American Cancer Society. DOI 10.1002/cncr.10662

We report a 42-year-old Japanese woman with Recklinghausen's neurofibromatosis 1 (NF1) who developed mixed connective tissue disease (MCTD). Previously experiencing good health without an increase in subcutaneous nodules, she presented with Raynaud's phenomenon, swollen hands and polyarthralgia Clinical examination revealed a high titer of anti-RNP antibody, and she was thus diagnosed as having MCTD. She was treated with oral prednisolone (10 mg/day) and her symptoms improved rapidly. Since the association of MCTD and NF1 has not been reported previously, we concluded that this association is rare. We also discussed the association of NF1 and autoimmune diseases including MCTD.

The value of establishing a patient-centered relationship within the context of the clini­cal encounter is well documented. The learner-centered method of medical education parallels the patient-centered clinical method; therefore, it should be explored as a method for teaching in the context of the learning encounter. In Japan and other Asian countries, rotations through services not related to the learner’s chosen medical specialty are mandatory parts of the medical intern­ship. Participation and effort in these rotations are often met with resistance from learners and are a common problem for medical educators. We adapted the counseling method for patients based on patient-centered methods such as motivational interviewing and solution-focused therapy to ad­dress this common problem. We show one case of a medical resident who lost his motivation to learn during his training. A resi­dent has many kinds of mental and physical stress. One such problem arises from the gap between what they want to do and what they have to do. Strategies from motivational interviewing and so­lution-focused therapy were adapted to successfully resolve a common teaching problem in Japan. A physician teacher (preceptor) helped this resident solve the issue for himself instead of arguing in favor of change. The positive aspects of the counseling method were based on patient-centered medicine and proved useful and effective in counseling for medical residents. We may take the les­sons learned from using patient-centered counseling methods to further develop a clear and system­atic process of counseling methods for residents to conduct learner-centered medical education. Keywords: learner-centered, patient-centered, motivational interview, solution-focused therapy, resident counseling

Carcinoid tumors generally appear as yellow/gray or tan submucosal nodules. We experienced a case of pedunculated rectal carcinoid showing a mushroom-like appearance. The case was a forty years old woman who was admitted to our hospital due to rectal bleeding. Colonoscopy revealed a pedunculated polyp presenting a mushroom-shaped appearance measuring 13 mm in diameter in the rectum. The histological diagnosis of specimens obtained by biopsy was adenocarcinoma and transanal ultrasonography revealed the tumor localization within the submucosal layer in the rectum. Endoscopic mucosal resection (EMR) was performed. Histopathological examination established the diagnosis of carcinoid tumor in the rectum. Frequencies of the pedunculated type in rectal carcinoids were reported to be 2.4% to 7.1% in the literature. Because of its rarity, pedunculated configuration may confuse the endoscopic diagnosis of carcinoids. Treatment for carcinoids of 1 to 1.5 cm in size remains controversial. Although such tumors are technically respectable by EMR, careful attention must be paid in dealing with these tumors because there may be unexpected behaviors of the tumors.