In Japan, it is necessary to develop the community medicine (community health care) because of the current of the medical practice. Since 1998, the community-based clinical clerkship (the two weeks' program) has been introduced to the all 5-grade medical students in Jichi Medical School. The aim of this program is to learn not only the knowledge and skill for the community medical practice, but also the attitude included the pleasure, enjoyment and worth to do it. The program contains as many activities of the community medicine as possible other than the out-patient or the in-patient managements. The most of medical students give good evaluation to the program. After the program, many of the medical students became to have the motivation to work in the rural area. In the undergraduate medical education, a community-based clinical clerkship will be more necessary in terms of the development of the community medicine.

Education in community medicine has become increasingly important. At Jichi Medical School, community-based clinicalclerkships began in 1998. This study examined the effects of a standardized program for medical facilities and clerkshipcontents introduced in 2001. A self-administered visual analogue scale questionnaire was given to 308 fifth-yearmedical students to examine their opinions about this program, community medicine, and the future. Results from beforeand after the introduction of the standardized program were compared. After the program had been introduced, significantlymore students agreed that the clerkship program was “meaningful” and should be continued. Furthermore, significantly more students agreed that “physicians enjoy working in the community, ” “talking with people, patients, and public officials is not difficult, ” and “ I will become a general physician or a specialist in the future.” These resultsshow that the standardized program is effective for education in community medicine.

Because of drastic changes in community health care in Japan, increasing emphasis has been placed on medical undergraduate education in community health care.The number of medical school introducing community-based clinical training is increasing.Therefore, effective clinical training in community health care should be developed. This study examined the effects of the location and subjects of training on students' evaluations and impressions of community-based clinical training.
1) Self-administered questionnaires were completed by 499 fifth-year students taking part in community-based clinical training.The main items were the locations and subjects of training and the students' evaluations and impressi ons of training. The associations between these items were analyzed.
2) A total of 96.8% of the questionnaires were analyzed. The students who trained only in clinics were slightly but not significantly more likely to have positive impressions of and to have given higher evaluation scores to training than were other students.
3) Students who participated in health education for healthy persons or patients or both were significantly more likely to answer that“the training program was enjoyable, ”“the preceptors were enthusiastic, ”and“I spent more time with the preceptors.”On the other hand, the students who took part in inpatient care were significantly less likel y to answer that“the training program was enjoyable”or that“the training program is needed.”
4) Students who studied 1 to 4 of the 11 subjects were significantly less likely than were students who studied 8 to 11 subjects to answer that“the preceptors were enthusiastic”and were less likely than were students who studied 5 to 7 subjects to answer that“the training was meaningful.”
5) Students who studied few subjects during training might have negative feelings about community-based clinical training.The experience of health education might have a positive effect on students.On the other hand, the experience of inpatient care probably has a negative effect.

This is a follow-up study to our 1999 telephone survey of education in complementary and alternative medicine (CAM) in Japanese medical schools. We surveyed the same workers in curriculum offices in all 80 Japanese medical schools in 2004. The number of medical schools that offer CAM education has increased significantly, from 16 schools (20%) in 1999 to 69 schools (86%) in 2004. Treatment with kampo is being taught in all 69 schools with CAM education. Fourteen (20%) of these 69 schools also teach a new framework of CAM and integrative medicine, and 7 schools teach evidence-based medicine in relation to CAM, although almost all schools (95%) taught kampo and acupuncture as types of traditional Asian medicine in 1999.

Japanese primary-care physicians recognize that narrative-based medicine (NBM) is important in clinical practice, but there is no standard method for training physicians in NBM. We conducted small-group learning in NBM for medical students at Jichi Medical University in 2005.
1) Our goals were to clarify what students learn and to investigate educational tools for teaching NBM.
2) We qualitatively analyzed responses to a questionnaire composed of 3 questions that the students answered freely after small-group learning involving an actual scenario based on a patient's narrative of home-care service and including evidence-based medicine and medical communication skills.
3) Students recognized that NBM is important in clinical practice. They also gained a deeper understanding of evidence-based medicine and medical communication skills, which are essential skills in primary care, and could integrate knowledge about primary care. Through discussion, they developed awareness of others and of themselves as doctors.
4) Small-group learning with an actual scenario and NBM increased students' awareness and stimulated their imagination. We believe that small-group learning is useful as an educational method in NBM.

Aim: To describe the current use of percutaneous endoscopic gastrostomy (PEG) in long-term care national health insurance facilities (special nursing homes for the elderly, health service facilities for the elderly, and long-term health care facilities), and assess whether its prevalence increased or not between 2007 and 2010. Methods: Based on data from the "Survey of Institutions and Establishments for Long-term Care" by the Ministry of Health, Labour and Welfare, we calculated the prevalence of residents with PEG in each type of long-term care facility in 2007 and 2010. Results: The prevalence of residents with PEG in 2007 versus 2010 was 5.8% versus 8.1% in special nursing homes for the elderly, 3.9% versus 5.9% in health service facilities for the elderly, and 18.4% versus 26.1% in long-term health care facilities. Among residents requiring level 3 or higher care, the prevalence of PEG increased in all three types of long-term care facility. Conclusion: From 2007 to 2010, the use of PEG increased among residents of long-term care facilities requiring level 3 or higher care.

To determine the need of guidelines for judgment of the bathing advisability for the aged in Councils of Social Welfare, we had a cross-sectional study in 1999.
A questionnaire survey by mail for Councils of Social Welfare which were extracted by systematic sampling (n=828, extraction rate was 25%) was conducted. The response rate was 83% and the proportion of respondents who answered the guidelines were necessary was 86% (n=642). Chi-square tests and logistic regressions analyses showed that bathing service in facility, existence of guidelines for judgment of the bathing advisability by body temperature, and respondents judging were independent factors associated with the need of guidelines for judgment on the bathing advisability in aged. Our results suggest the necessity to make guidelines for judgment of the bathing advisability in the aged.

Background: To date there had been no investigations using the International Classification of Primary Care, Second Edition (ICPC-2) at a clinic on an isolated island. In order to analyze health problems on the island, we investigated the reasons for visits, chronic illnesses, and the number of cases referred to other medical facilities using the ICPC-2.
Methods: The study was conducted over a 12-month period, from April 1, 2006 to March 31, 2007. Patient complaints/symptoms were classified according to ICPC-2, and diseases of patients who regularly visited the clinic as of November 2006 were investigated.
Results: Half of the patients that regularly visited the clinic had lifestyle-related or musculoskeletal diseases. On the first visit, several patients presented with cold, musculoskeletal, or skin symptoms. The specialist care to which the patients were most frequently referred was orthopedic surgery.
Conclusion: Physicians working at a clinic on an isolated island need to be able to control lifestyle-related diseases and provide initial treatment for musculoskeletal or skin diseases.

Background: Helicobacter pylori (H. pylori) infection has been reported to be associated with cardiovascular risk factors by inducing chronic low-grade inflammation and by influencing endocrine and metabolic systems, as well as the immunological response evoked by the host. This study investigated the association between H. pylori infection and high density lipoprotein cholesterol (HDL-C) in Japanese subjects.
Methods: The study subjects were 2,632 (1,061 men and 1,571 women) living in rural areas in Japan. We checked H. pylori serum immunoglobulin G (IgG), HDL-C and other cardiovascular risk factors in 1999.
Results: The overall prevalence of H. pylori seropositivity was 53.5% and increased with age. The prevalence was higher among men (58.3%) than women (50.3%). H. pylori seropositive women were more associated with decreased HDL-C than seronegative subjects (58.1±13.6 vs. 60.5±14.7, p<0.01). Multiple linear regression analysis with H. pylori seropositivity, age, body mass index (BMI), fibrinogen, blood glucose, and smoking and alcohol habits demonstrated that H. pylori seropositivity was a significant predictor of decreased HDL-C in women. In addition, there was a linear decrease in HDL-C with increments in the value of H. pylori antibody titer as a continuous variable in women. This association remained in H. pylori seropositive women aged ≥50 years. Moreover, H. pylori seropositive women with BMI <22 were associated with decreased HDL-C, whereas the association was not significant in women with BMI ≥22.
Conclusions: We show that H. pylori seropositivity is associated with decreased HDL-C, especially in women with a lower BMI in rural areas of Japan.

Abstract
Objective : To investigate the causes of fever of inpatients hospitalized in the Department of General Practice at Jichi Medical University Hospital.
Methods : We reviewed all medical records of the patients hospitalized in the Department of General Practice at this hospital between April 2003 and March 2004. Patients were selected as the “febrile group” by following criteria, 1) body temperature exceeded 37.5°C on admission, 2) fever and fever of unknown origin (FUO) were included in the clinical problems, and the causes of fever were described.
Results : A total of 464 patients were hospitalized and 221 patients (47.6%) were categorized as the “febrile group”. The most common cause of fever was infection (67.4%), followed by malignant disease (4.1%), collagen disease (3.2%), miscellaneous diseases (10.4%). 26 patients were classified as fever of unknown origin (FUO). Among FUO patients, collagen disease was the most common cause (34.6%), and undiagnosed cases was 26.9% that was similar to past reports. Although the rates of malignant disease and collagen disease were about sixteen percent in each generation from thirties to fifties as the cause of fever, only one patient met the criteria of classical FUO.
Conclusions : The most common cause of fever was infection. Systematic survey including hospitalization is needed early in case an outpatient doesn't cure fever unexpectedly. Noninfectious inflammatory diseases emerge as an important category of the causative disease of FUO.