Hospital-based Survey of Clinical Cases of Pesticide Poisoning in Japan 2007-2009 / 日本農村医学会雑誌

  Clinical cases of pesticide poisoning from 2007 through 2009 were analyzed based on data collected from the hospitals affiliated with the Japanese Association of Rural Medicine.<br>  Two hundred and twelve cases of pesticide poisoning were reported from 48 hospitals. By gender, males accounted for 54%. By age group, those in the 60-69 age band accounted for 23%, followed by those 70-79 years old (22%) and those 50-59 years old (19%). By month, the incidence peaked in May or August accounted for 12% respectively. When it comes to occupational poisoning, the majority of the cases occurred in spring and summer, when pesticides were used frequently.<br>  By type of pesticide exposure, suicide accounted for 77%, followed by occupation exposure (16%) and accidental ingestion (4%).<br>  By type of clinical manifestation, acute poisoning was most frequent (90%), followed by dermatitis (3%) and ocular disorders (2%). When it comes to occupational exposure, the rate of acute poisoning decreased to 70%, and dermatitis and ocular disorders increased to 11% respectively.<br>  Organo-phosphate insecticides topped the list of agricultural chemical compounds causing poisoning (32%), followed by amino acid herbicides (22%) and bipyridilium herbicide (10%). When it comes to main ingredients, glyphosate was the most frequent inducer (32 cases), followed by fenitrothion (25 cases) and paraquat (21 cases).<br>  Thirty-six death cases were reported, of which 16 cases were by paraquat and 9 cases by organo-phosphate insecticides. The death rate and number from paraquat poisoning were by far larger than those from any other pesticides. A ban on the use of paraquat must be considered.

An Attempt to Curb Overuse of Dialysis / 日本農村医学会雑誌

  The number of dialysis patients in Japan is increasing every year. The medical expense for dialysis patients has now surpassed well over 7 per cent of all medical costs. This has become a great burden on national finance. The D3-30 project was started in April 2006 for Toride city residents. The purpose of this project was a 30% reduction of the yearly number of new dialysis patients in three years. Toride city is located in southern Ibaraki prefecture; it had a population of 112, 152 in fiscal 2006, and 19% of the residents were over 65 years of age. The treatment procedure for chronic kidney disease (CKD) patients at the predialysis stage comprised the following four parts: 1. control of blood pressure, 2. mild restiction of protein and sodium intake, 3. administration of antiproteinuric drugs (angiotensin receptor blocker, angiotensin converting enzyme inhibitor, some calcium channel blocker, etc.), and 4. multifactorial treatment.  CKD patients were recruited through introductions from hospital registered doctors and public health nurses. Some patients entered voluntarily. The number of patients that started dialysis was counted by inquiring at the dialysis center of Toride Kyodo General Hospital and eighteen neighboring dialysis centers. In 2005, before intervention, 36 patients started dialysis; subsequently, the number of patients was 30 in 2006, 33 in 2007, 22 in 2008, and 23 in 2009. The rate of decrease was 39% in 2008 and, 36% in 2009, so the aim of the project was achieved.  If this treatment becomes widespread, it will contribute greatly to the curtailment of medical expenses. However, the difficulty of the treatment may hamper its spread. For it to spread, it is necessary to add the new medical fee for guidance and management for CKD patients.

The Significance and Usefulness of Evaluating the Serum Level of IgG Class Antibody for Helicobacter pylori in Annual Multiphasic Health Check-up Participants / 日本農村医学会雑誌

  Recently, the relevance of Helicobacter pyroli (H. pylori) infection to atrophic gastritis and gastric cancer in has been elucidated. Therefore, to diagnose H. pylori infection is important for suspecting the existence of those diseases of the stomach. We investigated the relationships of the H. pylori IgG antibody to H. pylori infection, atrophic gastritisor various stomach lesions to understand the significance and usefulness of evaluating the antibody level in the annual multiphasic health check-up participants. The subjects in this study were 148 people (male: 93, female: 55, average age: 56.4) in Toride city, which is located in the suburb of Tokyo. They had visited our hospital for medical checkups. Eighty-seven subjects underwent upper gastric endoscopy and 55 (63%) tested positive for H. pylori IgG antibody and H. pylori infection was confirmed in 41 (75%). Although 32 subjects tested negative for the antibody, 8 cases (25%) was diagnosed with H. pylori infection. The frequencies of positive antibody in atrophic gastritis, erosion and ulcer, fundic gland polyp, hyperplastic foveolar polyp, adenoma and malignancy were 17%, 70%, 61%, 77%, 31%, 62%, 0% and 100%, respectively. On the other hand of 80 subjects were who underwent barium X-ray examination, 44 tested positive for the antibody (55%). The frequency of positive antibody in no lesion, depressed lesion, elevated lesion and malignant lesion were 61%, 59%, 36% and 100%, respectively. Taken together, H. pylori antibody was a good marker for H. pylori infection and the positive antibody indicated high frequencies of atrophic gastritis and malignancy. Therefore, advices to have participants who have a positive antibody should be strongly an endscopic examination stomach lesions.

Nontuberculous Mycobacterial Peritonitis in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis / Journal of Rural Medicine

Non-tubercuous mycobacterial (NTM) infection in peritoneal dialysis (PD) patients has been rarely reported. We report a case of a 55-year-old female on continuous ambulatory peritoneal dialysis (CAPD). After a 2-year-history of recurrent exit-site infection of a PD catheter caused by Mycobacterium abscessus (M. abscessus), the patient was admitted to the hospital with signs of peritonitis. Since the same species, M. abscessus, was isolated from the CAPD effluent, multiple antibiotics were administered. However, the treatments could not relieve the symptoms of her infection. Consequently, the PD catheter was removed. Her condition gradually recovered over the course of subsequent, long-term, empirical antimicrobial therapies. NTMs, especially a rapidly growing NTM infection, have rarely been reported in PD patients and are commonly resistant to a variety of antimicrobial agents. Routine acid-fast staining is most likely helpful in promptly initiating treatment against NTM infection in PD patients. Moreover, an appropriate treatment regimen for a rapidly growing NTM infection should be established by accumulating data from cases as reported here.

Conservative Treatment of Chronic Kidney Diseace (CKD) / 日本農村医学会雑誌

In Japan, the number of dialysis patients as of the end of fiscal 2007 has hit the 275,000 mark. The nation is now ahead of the rest of the world in the number of patients per million population. The largest problem that confronts us is that the enormous cost of dialysis is putting a great strain on the nation's finances. In addition, it should be mentioned that the quality of life of dialysis patients is aggravating. It is very rare for renal disease patients to receive kidney transplants, because only 200 kidneys are offered per year in Japan. So most of the patients have no choice but to depend on dialysis for the rest of their life.In the treatment of chronic kidney disease (CKD), it is important to for physicians to delay initiating dialysis as much as they can in Japan. In 1987, I began the programmed treatment of patients in a predialysis state with two nephrologists. The treatment is based on the “Toride guidelines for CKD”. There is an annual meeting of patients. Laboratory data and the history of medication are preserved in sheets.In the CKD clinic of our hospital, there are many devices for time-consuming. Full laboratory data apear quickly on the computer panel, and a clerk enters main data in patients, CKD records.The principles of the clinic iuclude control of office blood pressure and home blood pressure, mild restriction of protein intake, salt intake restriction, monitoring the diet from the data of 24 hours urine collection, control of hemoglobin concentration, serum bicarbonate and phosphate concentration. Reduction in urine protein excretion to less than 0.5 gram per day is done by dietary protein restriction, control of blood pressure and administration of angiotensin converting enzyme inhibitor or angiotensin receptor blocker.The outcomes of the Toride Cohort Study in the past 21 years are as follows:1. Reduction in medical cost by slowing the progression of CKD;2. Reduction in the dialysis-to-non dialysis rate;3. Appearance of the “arrested” or “remission” cases; and;4. Detection of the new risk factors for progression of CKD such as hyperphosphatenia and metabolic acidosis by multivariate analysis.There is a bare possibility open for a CKD patient to receive the “right” treatment of CKD, because only four to five clinics adopting the Toride guidelines are available in Japan.Physicians in CKD clinics have to judge and adjust many variables. The clinics spend plenty of time and effort on the treatment of CKD.In Japan, the medical fee in clinics is dependent on the number of visiting patients and on the number and quality of laboratory examinations, so the physicians keep away from CKD clinics.For the reduction of cost of dialysis, spread of “right” treatment is needed. For spread of the treatment, additional medical fee per patient visit is necessary as incentive.

Success in Energy Consumption in our Hospital / 日本農村医学会雑誌

A reduction in electricity and heating expenses is a major consideration with every hospital in Japan. In our hospital, all the personnel including the members of the facilities division have joined forces to mount the “1,300kW campaign” aimed at cutting down on the amount of maximum instantaneous electric power consumption (demand) from 1,500kW to 1,300kW in one year, and succeeded in curtailing heating and lighting expenses by well over 4 million yen. The key to success was how to control the amount of demand. The cooperation of all the personnel of the hospital was vital. Therefore, it was important to raise the awareness of all the personnel concerning energy conservation. We thought that setting the concrete numerical target “from 1,500kW to 1,300kW” was effective. It is no exaggeration that such a cutback in energy consumption contributes not only to the management of a medical institution but also to the environmental preservation on a global scale. Finally, the medical institutions should put contribution to the community into the basic principles at the time when environmental preservation (ecology), energy consumption reduction, risk management and catastrophic disaster etc. have become topics of conversation.

Marchiafava-Bignami disease with only slowly progressive cognitive impairment / Journal of Rural Medicine

We report on a right-handed 43-year-old policeman with atypical Marchiafava-Bignami disease (MBD). The typical clinical manifestations of MBD are reduced consciousness, confusion, seizures, psychotic and emotional symptoms, hemiparesis, dysarthria, ataxia, and coma and death. However, our patient had not developed any of the above symptoms except for slowly progressive cognitive impairment mimicking that of Alzheimer disease. The incidence of MBD may be higher and its prognosis less severe than generally believed. MBD has been underdiagnosed and underreported, and nonspecific general symptoms and encephalopathy in an alcoholic might indicate undiagnosed MBD.

Atypical Miller Fisher syndrome with complete bilateral ophthalmoplegia mimicking brainstem stroke / Journal of Rural Medicine

We report on three elderly patients with stroke-like onset of atypical Miller Fisher syndrome (MFS). The serum titer of anti-GQ1b IgG was markedly elevated in these patients. Their prognoses were sufficiently good with immunoadsorption therapy with or without intravenous immune globulin (IVIg) therapy. However, some neurological findings were not characteristic of typical MFS. Patient 1 suffered from prolonged dysesthesia in her left extremities, and Patients 2 and 3 showed no ataxia. Moreover, complete bilateral gaze limitation is rare in MFS. The sudden stroke-like onset along with the gaze limitation of these patients suggests that the unexpected elevation in the serum titer of anti-GQ1b IgG due to unknown immune dysregulation might have severely affected the third, fourth, and sixth nerves and this potent antibody rapidly attacked these nerves and induced stroke-like clinical features and complete ophthalmoplegia.

Autoimmune Pancreatitis Developing Remarkable Collateral Circulation Around the Pancreas / Journal of Rural Medicine

A 65-year-old man was referred to our hospital in April 2003 with a pancreas tumor detected by a thorough medical checkup. Computed tomography (CT) showed swelling of the pancreatic body and tail, and magnetic resonance cholangiopancreatography (MRCP) showed only the main pancreatic duct in the head of the pancreas. Diagnosing autoimmune pancreatitis, we observed the patient without medication. However, one year later CT showed stenosis of the splenic artery and portal vein accompanied by development of collateral circulation around the pancreas. He had no symptoms, and CT showed no changes in the pancreatic swelling.;;He was admitted to our hospital on January 6, 2005, presenting with a history of jaundice which first appeared on January 1, 2005, and increased collateral circulation around the pancreas with pancreatic swelling were seen on CT. We started prednisolone therapy at 40 mg/day for exacerbation of autoimmune pancreatitis. Serum bilirubin levels improved from 11.9 mg/dl to 2.5 mg/dl, and pancreatic swelling also improved four weeks after starting therapy.;;We present a rare case of autoimmune pancreatitis that developed marked collateral circulations.

Peritoneal Dialysis (PD) Terminal: A Rescue Treatment for Uremic Patients with Massive Ascites Related to Malignancies / Journal of Rural Medicine

Dialysis therapies are generally considered to be contraindications in cases with non-curative malignancies. Here we report two cases in which peritoneal dialysis was undertaken to reduce malignancy-related symptoms like abdominal full sensation and anorexia as well as to eliminate uremic toxins. The first case was a 61year-old male with peritonitis carcinomatosa and its related ascites disseminated from pancreas tail cancer. His renal function deteriorated after initiating chemotherapy using 1,000mg/m² of gemcitabine (GEM), and dialysis was required to improve his uremic symptoms. The second case was an 81year-old male who had been receiving maintenance HD therapy for 8years at another clinic. He had been complaining of abdominal distension derived from ascites and had multiple liver tumors of unknown origin. Since the main complaint in these two cases was unbearable abdominal full sensation, continuous ambulatory peritoneal dialysis (CAPD) was initiated to simultaneously control uremia and to relieve the abdominal distension. CAPD was successful in reducing ascites and in controlling the uremia as well as general symptoms. Consequently, we propose “PD terminal” as the rescue treatment for uremic patients with massively retained ascites related to malignancies.

False-negative and False-positive Diffusion-weighted MR Findings in Acute Ischemic Stroke and Stroke-like Episodes / Journal of Rural Medicine

Background: Diffusion-weighted magnetic resonance (MR) imaging (DWI) is an excellent examination for detecting acute ischemic stroke, but false-negative cases have been reported recently.Patients and Methods: Since the present MR scanner (1.5-T, Siemens Symphony) was introduced to our hospital, a prospective study was designed in the Departments of Neurology and Radiology to evaluate the DWI findings in patients tentatively diagnosed to have an acute infarction and in those with stroke-like episodes. During the 31 months between June 2000 and December 2002, 572 consecutive patients with acute cerebral infarction or presenting conditions mimicking ischemic stroke, including transient ischemic attack (TIA), sudden-onset isolated vertigo, and loss of consciousness (LOC) with or without seizure, underwent DWI.Results: Four of 366 patients with a cerebral infarction (1.1%) had false-negative DWI in the acute stage, and 10 of 206 patients with conditions mimicking ischemic stroke (4.9%) had false-positive DWI in the acute stage. Of these 10 patients, there were five cases with TIA, four with sudden-onset isolated vertigo, and 1 with LOC with seizure. Sensitivity and specificity values were 98.9% and 97.6%, respectively, when DWIs were performed to diagnose acute cerebral infarction.Conclusion: DWI rarely fails to detect an acute-stage cerebral infarction, but further confirmatory measures may be necessary when there is a negative examination using a clinical or computed tomographic diagnosis to the contrary.

Burdens to Family Members in Home Care and Related QOL Factors / 日本農村医学会雑誌

This study was conducted to shed light on the actual conditions of home care and quality-of-life factors related to the burdens on families. For this purpose, a survey was carried out on main caretakers in the families who were using our home care support service. Fundamental information about the main caretakers and those who need care were garnered. In addition, WHO/QOL-26 and burdens for main caretakers were checked up on.The survey found that those who have looked after the sick or invalid for less than six months and those over five years keenly felt that they were shouldering a heavy burden. With the progression of dementia, the caretakers increasingly felt the burden getting heavier. Physical factors in QOL were linked to the burden which caretakers feel has to be borne, but psychological and social factors were not. This finding might have been ascribed to the fact that the persons surveyed were residents of the provincial city, part of which is rural. They were mostly old women and must have gained the support of their relatives. It is easy to assume that their role perception and sense of responsibility together with regional characteristics were reflected in psychological and social QOL factors.

Clinical Significance of Serum Leptin Levels in the Diagnosis of Fatty Liver / 日本農村医学会雑誌

We examined the usefulness of serum leptin concentration as an index for the diagnosis of fatty liver. Twenty-two patients diagnosed with fatty liver by abdominal ultrasonography, participated in this study together with 7 indinduels as controls. As laboratory findings showed, body fat percentage (29.5±1.4 vs 19.1±1.6%, P<0.001), BMI (25.7±0.7 vs 20.8±1.0 kg/m2, P<0.005), procollagen III peptide (P III P) (0.58±0.04 vs 0.42±0.04 U/ml, P<0.05), and serum leptin levels (7.3±1.0 vs 2.9±0.5 ng/ml, P<0.001) were significantly higher in the fatty liver group than in the control group. Serum leptin levels were correlated significantly with body fat percentage (r=0.76, P<0.0001) and BMI (r=0.61, P<0.001), though there was a significant correlation between serum leptin levels and liver-kidney contrast (r=0.47, P<0.05) only in males. In addition, when the fatty liver group was classified into two groups by GPT levels, m-GOT (mitochondrial glutamate-oxaloacetate transaminase) (8.6±1.0 vs 5.7±1.0 IU/l/37°C, P<0.05) and P III P (0.65±0.06 vs 0.49±0.04 U/ml, P<0.05) were significantly higher in the elevated GPT group than in the normal GPT group.These results suggest that serum leptin levels may be indicative of fatty liver and that fatty liver is not always a reversible disease.

Usefulness of NS5 Antibody Measurement in Recombinant Immunoblot Assay (RIBA) as a Clinical Test for Confirmation of Asymptomatic HCV Infection / 日本農村医学会雑誌

Using RIBA NS5 antibody was measured in 31 HCV RNA positive serotype 1 patients, and the serum levels of ALT were monitored for an average of three years. As a result, 22 asymptomatic HCV carriers (group A) were found to be NS5 antibody negative (-) and nine to be NS5 antibody positive (4+). By contrast, in 25 patients with chronic inactive hepatitis C (group B), three patients were NS5 antibody negative (-), and 22 patients were NS5 antibody positive (4+), indicating a significant difference between the two groups (p<0.01 chi square test).Furthermore, in group A, 22 NS5 antibody (-) patients (group I) maintained normal serum levels of ALT significantly longer than the 9 NS5 antibody (4+) patients (group II) (p<0.01, Kaplan-Meier Method). Therefore, the measurement of NS5 antibody of RIBA was clinically useful in identifing asymptomatic (HCVRNA positive, serotype 1) HCV carriers.

Improved Incident/accident Reporting System by Group-working Analysis and Originally Developed Management Scores / 日本農村医学会雑誌

Safety management in routine medical practice is one of the important issues that must be addressed by medical staffs, even it is hard to deal with various happenings and problems encountered in medical facilities.Here we present some arrangements in a reporting system of incidents and accidents to motivate each staffer to notice the significance of safely, and quantify the urgency and severity of reports using the originally developed management score at the Toride Kyodo General Hospital.The reports from all sections of the hospital were previously evaluated by five risk managers. This practice was effective in analyzing reports rapidly and appropriately, but was insufficient to motivate all of staffs to give much more heed to safety in routine medical practice. Instead, these reports are now discussed and analyzed by a group of people consiting of representatives of all sections and the departments in the hospital. This innovation evoked more interest and concerns about the safety management among the whole medical staff.We also utilized the management level, which was stratified into three grades from the point of urgency and severity of cases. The first level means the occurrence without urgency or need to change any systems, procedures and organizations. The second level requires some change in systems, but no urgent action. The accident at the third level should be dealt with as soon as possible by any of feasible ways. The total score, obtained by summing up a lisk level multiplied by a management level in each report, decreased between May and August in 2004, despite increases in the total numbers of monthly reports.In conclusion, the incident/accident reporting system became more familiar to medical staffs through the use of group-working. The management score and the derived total score may be available for comparing outcomes of safety management activities among different observation periods or facilities.

The Role of Low Protein Diet (LPD) in the Treatment of Chronic Kidney Disease (CKD) / 日本農村医学会雑誌

There is such an opinion that low protein diet (LPD) is unnecessary for preventing progression of renal insufficiency in chronic kidney disease (CKD). However, three randomized control trials of nondiabetic nephropathy (NDN) with CKD, using a metaanalysis method, revealed the usefulness of LPD in preventing progression of renal insufficiency. It is thought that the usefulness of LPD may increase further, if we evaluate randomized control trials one by one and select only what has high quality.<BR>WHO/FAO recommended 0.8 g/kg/day of daily protein intake (DPI) to healthy people from a viewpoint of illness prevention 30 years ago. As, in advanced nations, DPI is 1.1 to 1.3 kg/day/kg in every country, DPI of CKD will become the same level of healthy people if not regulated. It cannot be considered at all that protein restriction is not required for CKD who is more susceptive to cardiovascular diseases than healthy poeple.<BR>In conclusion, we should monitor DPI of patients with CKD, and control DPI between 0.6 and 0.8 g/kg/day. Under the restriction of DPI, we should manage NDN with CKD to prevent progression of renal insufficiency by controlling blood pressure, suppressing rennin-angiotensin system, compensating acidosis and correcting renal anemia.

Maintenance of Respirators, Warmers and Humidifiers by the Central Safety Management Unit / 日本農村医学会雑誌

The maintenance of life-supporting systems, such as respirators, has been the responsibillity of the central management unit since December 1991. The in-house unit was set up to ensure a high-quality level of maintenance and safety of medical equipment.<BR>We analyzed the incidence of trouble with respirators between 1995 and 1999, based on the logs of the machines and check lists. Fifty-one percent of the incidence was found by medical engineers while they were making their rounds of inspection in the wards, thirty-four percent during periodical checkups at the central safety management unit, and fifteen percent upon request for examination. The faults in warmers and humidifiers attached to the respirators were found only at the wards or upon request for examination. The causes of trouble in the respirators were mechanical failures rather than human error. The mechanical factors was responsible for the incidence 2.9 times as much as human factors. The incidence of trouble associated with the warmers and humidifiers notably dropped after the types of instruments were unified in 1997. To ensure safety, we came to the conviction that the dual check system-the regular inspection at the central safety management unit and the engineers' rounds of inspection-is very effective. The selection of appropriate instruments was also important.

Drug Use in Renal Insufficiency, Drug-induced Nephropathy / 日本農村医学会雑誌

We should decide the dose in renal insufficiency according to an attachment document, estimated by Cockroft-Gault's formula. It is better not to decide the dose only byexcretion route. In addition, we should not administer the nephrotoxic drugs, especially NSAIDs, to renal insufficiency.<BR>Also, it is necessary to pay enough attention to the overdose of drugs, which do not cause renal toxicity but cause dangerous side effects to the central nervous system.<BR>Many attachment documents have a lot of lacks in the mention for renal insufficiency and need to be improved.

Four Cases of Eosinophilic Gastroenteritis / 日本農村医学会雑誌

Eosinophilic gastroenteritis (EG) is characterized by infiltration of eosinophils into the wall of the digestive tract, and the clinical spectrum seems to depend on the predominant site of eosinophilic infiltration of the wall.<BR>We experienced four cases of EG, and two of them (Cases, 1 and 2) manifested massive ascites, suggesting the principal lesion is located on the serous coat. Case 3 manifested abdominal pain and vomiting, and muscle layer involvement of the duodenum was detected by ultrasonography and CT scan. In case 4, epigastralgia was a main symptom. An endoscopic examination revealed marked redness and erosion of the gastric mucosa associated with massive infiltration of eosinophils. In this case, mucosal involvement seemed to be the main lesion because hypertrophy of the gut wall thickness was not found by ultrasonography and CT scan.<BR>Although the pathogenesis of this disease is obscure, allergic mechanism may play an important role. Three cases had histories of allergic diseases, and steroid therapy resulted in prompt disappearance of symptoms.

A Study of Self-sufficiency of Food in Japan / 日本農村医学会雑誌

Japan's food self-sufficiency rate has fallen off to around 40%. A questionnaire survey of residents of Toride-city reveals that 60% of the citizens are concerned about this low self-support rate. Even junior and senior high school students are anxious about this situation.<BR>It is feared that world food production will not increase in proportion the rise in demand from now on by the influence of global warming. There is a possibility that foods supply could be temporarily cut off by the interruption of shipping lanes considering the unstable political conditions around Japan.<BR>Although the decline in the self-sufficiency rate should be discussed as a fundamental subject of the country, the mass media of Japan do not take it up seriously. The mass media would not show how to deal with the food crisis, but only blame it as a result of the unreasonable agricultural policy.<BR>Since 1993, Japan has approved minimum access of rice import, because the GATT and WTO put pressure on the Japanese government to approve the liberalization of the rice market. In 1999, rice tariffication was put into effect. The mass media and the government are afraid of the import restriction by foreign nation of industrial products from Japan as a result of the opposition to rice import in the name of food security.<BR>The opening of the rice market will increase the imports of rice and the rice growers of Japan will sustain serious damage. Countries other than the U. S. and the Cairns Group will understand the Japanese assertion of food self-sufficiency as Japan is an island country. After reaching an agreement with the developing countries and NGO on this matter, Japan should revise the WTO agreement.<BR>Although a farm village should retain some original scenery of Japan, housing styles and colors of a farm village in Japan are in total disarray. We want to propose to build 10-20 “model farm villages” in the country. If the model farm village retains Japanese original scenery, many city residents visit it and the image of an old farm village will give them a good impression, opening up the possibility of green tourism. If the model farm village gets a good reputation, the number of farm villages which hope to retain Japanese original scenery will increase and regain the rural beauty.<BR>It is also important for a farm village to return to its original recycling life style. In Europe, it is a prevailing practice to recycle the garbage discharged from a farm village, including excretions of livestock, straw and so forth. And the technology, that changes biomass into methane or ethanol has been developed and become commercialized in Europe. It is important for a farm village to introduce such a technology and aim at a circulation style society more promptly than a city.<BR>The Japanese Association of Rural Medicine should conduct a long-term prospective epidemiological survey to clarify whether the decrease in carbohydrate intake including rice and the increase in the ingestion of animal food have some relations with the recent rapid increase of diabetes. It will not be impossible to do so if collaboraion from medical examination centers across the country is obtained. If it becomes clear that the present eating habits are not good for our health, the rice-based diet revives and the demand for rice grows. And Japan's food self-sufficiency rate will go up in the long run.