Meta-analysis for epidemiologic studies on the relationship between smoking and Parkinson's disease.

Many epidemiologic studies on the relationship between smoking and Parkinson's disease (PD) have been conducted. Morens et al. reviewed many articles in the study field and concluded that smoking is inversely associated with the risk of PD. In the present study, the object is to obtain summarized risk estimates of the relationship from the published articles using meta-analysis. Summarized risk estimates on the relationship between smoking and PD were found to be about 0.5 with statistical significance in meta-analysis. Therefore, the result that smoking is inversely associated with the risk of PD is appropriate.

Cadmium absorption from smoking cigarettes: Calculation using recent findings from Japan.

Consumed substances, including food, drink, and tobacco, produced in the environment are exposure sources of Cd. The object of the present study was to estimate Cd exposure and absorption amount from smoking cigarettes, one exposure source of Cd, using recent findings from Japan. The market share of cigarettes produced in foreign countries has increased in Japan, the proportion of tobacco leaves harvested in foreign countries has increased in cigarettes produced in Japan, and the percentage of smokers in Japan has changed. Therefore, obtaining the absorption value of Cd from smoking cigarettes using recent findings from Japan is significant.We collected information on (1) the concentrations of Cd in tobacco leaves by country of harvest and in cigarettes by country of production, (2) the concentrations of Cd in cigarette smoke, (3) the proportion of tobacco leaves harvested in foreign countries used in cigarettes made and sold in Japan, (4) the absorption rate of Cd in the airways for cigarette smoke, (5) the smoking rate by gender, age, and year in Japan, (6) the number of cigarettes sold in Japan by year and country of production, (7) the number of cigarettes smoked by smokers per day according to gender and age in Japan, and (8) the population size in 1998 by gender and age in Japan. The mean amount of Cd absorbed via the airways by smoking for smokers in Japan was calculated to be 0.89-1.78 µg/day from the above information. The values are not small in comparison with the amount of Cd absorbed from the digestive organs.The concentration of Cd in tobacco leaves harvested in Japan and cigarettes produced in Japan is generally higher than that of leaves harvested and cigarettes produced in foreign countries. The increase in the market share of cigarettes produced in foreign countries and sold in Japan and the increase in the proportion of tobacco leaves harvested in foreign countries used in cigarettes made and sold in Japan have decreased the amount of Cd absorbed by smoking for smokers in Japan.

Validity of cadmium concentration in rice as the "dose" of the dose-response relationship between cadmium intake and renal dysfunction.

It is well known that cadmium (Cd) causes renal dysfunction such as increase of beta(2)-microglobulin excretion into urine. Although Cd in rice seems to be one of the largest sources of total Cd intake in Japan, there are very few studies that have epidemiologically clarified the relationship between Cd concentration in rice (Cd-R) and renal dysfunction, because such studies are basically ecological studies, in which confounding factors are difficult to take into consideration. To derive safety levels for foodstuff from Cd-R, it is essential to evaluate the effect of confounding factors. Thus, we investigated the dose-response relationship between renal dysfunction and not only Cd-R but also confounding factors, and we tried to determine whether Cd-R is an adequate indicator of "dose" in the dose-response relationship between Cd intake and renal dysfunction. In 1971, Cd-R data were obtained from rice samples collected by the Environment Agency, Government of Japan in the Fuchu area of Toyama Prefecture, which is known as a place where many itai-itai disease patients were found, and medical data were collected during 1979-1984 by Toyama Prefecture. First, the dose-response relationship between Cd-R and renal dysfunction was analyzed using the data from the Fuchu area. Second, to investigate the effect of confounding factors, analysis using the data from both the Fuchu area and an unpolluted area with environmental factors different from those of the Fuchu area was performed. The results showed that the cause of renal dysfunction could not be explained by Cd-R alone, and confounding factors were not negligible. Although it is difficult to clarify precisely the confounding factors from the available data, it is concluded that deriving a safety level for foodstuffs using only the Cd-R level as a reference is not appropriate.

[Relationship of dietary habits pattern and body build of parents to child obesity].

Patterns of eating habits were analyzed to elucidate its relationship to the temporal change of body build from childhood through school age in subjects of the Toyama study. Survey questionnaires at the time of entrance to elementary school were used. Subjects were 6,452 (males 3,293, and females 3,159). Subjects were classified into 6 clusters among the males, 8 clusters among females based on the results of cluster analysis of eating habits. The cluster in males that preferred egg, milk, dairy products, fats, fish and shellfish, soybeans, fruits, green yellow vegetables indicated more frequent subjects whose BMI were less that 14. The cluster in girls that preferred fats indicated more frequent subjects whose BMI were more or equal to 18. The ANOVA showed significant relation of parental body build on their children. Even after grouping by parental body build, the cluster based on patterns of eating habits showed different frequencies of obese children. Preference for intake of milk indicated less frequent obese children among the similar parental body build for boys, while preference for intake of fats indicated more frequent obese children among a similar parental body build for girls. In conclusion, the obesity of a school child has a close relationship to parent's body build. However, the temporal changes of obesity were seen among eating habits clusters even if body builds of their parents are the same. It was shown that patterns of eating habit are important in school children's obesity development.

Temporal course of the development of obesity in Japanese school children: a cohort study based on the Keio Study.

OBJECTIVE: To demonstrate the temporal course of obesity development in Japanese school children by conducting a school-site cohort study over 12 years. METHODS: From 1981 to 1984, height and weight of 479 subjects (343 boys and 136 girls) were measured every year from entrance into primary school until graduation from high school in Tokyo. Obese children were defined as those with a body mass index (BMI) at or above the age-sex-specific standard value, derived from Japanese nationwide data. RESULTS: Approximately 50% of the children who were obese in the primary school period were obese at age 17. Likewise, 40% who were obese in the junior high school period and 70% who were obese in the high school period were obese at age 17. Among 44 children who were obese at age 17, 14 showed tracking of obesity from the preschool period, 14 showed tracking from ages 7 to 11 years, 10 showed tracking from the junior high school period, and 6 showed tracking from the high school period. CONCLUSIONS: Among children who were obese at age 17, most tracked from the primary school age or earlier. The earlier the tracking commenced, the greater the BMI at age 17. This indicates the importance of conducting health education for school children at an early age.

Influence factors on the development of obesity in 3-year-old children based on the Toyama study.

BACKGROUND: Obesity in childhood increases the risk of obesity in adulthood. Obesity in adulthood is a risk factor for chronic diseases such as hypertension and atherosclerosis. Therefore, it is important to eliminate factors influencing the development of obesity in children from the viewpoint of preventive medicine. The purpose of this study is to elucidate the relationship between obesity and lifestyle in 3-year-old children in a case-control study. METHODS: Subjects were selected from the Toyama study at health checkups for 3-year-old children which are done routinely by local governments in Japan on all children of that age. A special questionnaire consisting of items on lifestyle and environmental factors of the children and past histories of parents was distributed to the Toyama study participants beforehand and was collected at the checkup. Matched-pair comparisons were performed between obese children whose body mass index was 18 or more (N = 427) and control children (N = 854) matched by sex and birth month. Multivariate stepwise conditional logistic regression analysis was also applied to assess the influence of confounding factors. RESULTS: The following six factors significantly influenced the development of obese 3-year-old children using the Mantel-Haenszel method: the mother's job, limited playtime outdoors (1 hour or less), snacking irregularity, an overweight father (body mass index >/= 24), an overweight mother (body mass index >/= 24), and overweight at birth (birth weight >/= 3,500 g). An overweight mother or father, limited playtime outdoors, overweight at birth, and snacking irregularity were significantly related to obesity in 3-year-old children after adjusting for confounding factors by multivariate stepwise conditional logistic regression analysis. CONCLUSIONS: We have suggested several factors influencing the development of obesity in 3-year-old Japanese children: parental overweight and overweight at birth as host factors, physical inactivity and snacking irregularity as behavioral factors, the mother's job as an environmental factor.

HRA model for hypercholesterolemia based on a longitudinal health database.

To evaluate the risk factors for hypercholesterolemia, we examined 4,371 subjects (3,207 males and 1,164 females) who received medical checkups more than twice at an AMHTS in Tokyo during the period from 1976 through 1991; and whose serum total cholesterol was under 250 mg/dl. The mean follow-up duration was 6.6 years. A self-registering questionnaire was administered at the time of the health checkup. The endpoint of this study was the onset of hypercholesterolemia when the level of serum total cholesterol was 250 mg/dl and over. We compared two prognosis groups (normal and hypercholesterol) in terms of age, examination findings and lifestyle. After assessing each variable, we employed Cox's proportional hazards model analysis to determine the factors related to the occurrence of hypercholesterolemia. According to proportional hazards model analysis, total cholesterol, triglyceride and smoking at the beginning, and hypertension during the observation period were selected in males; and total cholesterol at the beginning and age were selected in females to determine the factors related to the occurrence of hypercholesterolemia.

Health risk assessment for diabetes mellitus based on longitudinal analysis of MHTS database.

This study was designed with a follow up of 16 years to provide the epidemiological model evaluating the risk of developing diabetes mellitus in Japan. A cohort of 2573 subjects (1851 males and 722 females) from a MHTS in Tokyo, who were nondiabetic (fasting blood glucose (FBS) less than 110 mg/dl) in the initial year, were selected. This cohort was followed every year to identify the occurrence of diabetes mellitus. Diabetes Mellitus was defined as fasting blood glucose over 110 mg/dl, or the initiation of diabetic therapy. We compared two prognosis groups (a normal group and a diabetic group) in terms of age, examination findings, and prevalence of health risks (lifestyle, stress, and working form). We also assessed family history of diabetes and past histories including hypertension, hypercholesterolemia, and hyperuricemia. After assessing each variable by univariate analysis (t-test, chi 2 test), we employed Cox's proportional hazards model analysis. We used stepwise model adopting risk factors. The diabetic group had significant differences compared to the normal group in age, BMI (body mass index), FBS, smoking, drinking, not eating breakfast, dairy intake, hypertension, hypercholesterolemia, hyperuricemia, and family history by univariate analysis. According to proportional hazards model analysis, FBS, age, family history, hypertension, smoking, and BMI were incorporated into significant risk factors for diabetes in males, and not eating breakfast, FBS, age, drinking, and hypertension were incorporated in females. Diabetes seemed to be related to fixed factors (age), or genetic factors (family history and FBS) in males. For females, lifestyle (not eating breakfast and drinking habit) seemed to play an important role. It will be worthwhile to assess the risks of developing diabetes mellitus by this epidemiological model.

Per capita gross national product and summarized odds ratio for epidemiologic studies on the relationship between passive smoking and lung cancer.

The summarized odds ratios of epidemiologic studies on the relationship between exposure to environmental tobacco smoke (ETS) and lung cancer by country were recalculated, using the odds ratio values in a 1992 report entitled, "Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders" by the US Environmental Protection Agency. The relationship between the summarized odds ratio and per capita gross national product (GNP) in 1964 was studied by the country. The graphic relationship between the summarized odds ratio (ordinate) and GNP (abscissa) showed an upward convex curve. The summarized odds ratios of a developing country (China) and developed countries (USA, Western Europe) in 1964 indicated a very weak association, while those of other countries (Greece, Hong Kong, and Japan) were slightly greater than unity (1.0). This means that ETS in the developing and developed countries in 1964 hardly affected lung cancer, whereas that in the other areas affected lung cancer somewhat. Socioeconomic status in developed countries is far better than that in developing countries, and factors related to socioeconomic status may affect the summarized odds ratio. It is recognized that cancer is diagnosed clinically some years after cancer risk factors appear. If the socioeconomic status involves some risk factors which affect lung cancer, the relationship between the summarized odds ratio and the GNP may be significant. Therefore, we can forecast that the summarized odds ratio of Japan will decrease to close to unity and that that of China will increase in the future because of economic growth, making it possible for the Chinese Government to adopt a policy to reduce the influence of ETS on health.

[The effect of quality of life in Behçet disease patients on subjective life satisfaction].

The purpose of this study is to elucidate the relationships between subjective life satisfaction and the following 8 factors of quality of life: physical condition, daily living activities, working condition, economic status, social status, medical status, marriage status, mental status. One hundred and fifty-four male and 116 female Behçet patients in 13 medical facilities were analyzed in this study. Mantel-Haenszel's odds ratio method and stepwise logistic regression analysis were applied to evaluate the influence of quality of life on subjective life satisfaction in Behçet disease patients. Males had higher problem scores than females in the following: physical condition, daily living activities, working condition, economic status, social status, marriage status, mental status. With regard to the effect on subjective life satisfaction, physical condition, daily living activities, working phase, economic phase, social phase, marriage relations, mental phase showed significantly high odds ratio in male, while physical condition, working phase, economic phase, social phase, medical phase, marriage relations, mental phase showed significantly high odds ratios in females by Mantel-Haenzel age-adjusted method. Physical condition, daily living activities, working phase, economic phase, social phase, and mental phase showed significantly high odds ratios in males after adjusting for active disease symptom periods, while physical condition, working phase, economic phase, social phase, medical phase, marriage relations, mental phase showed significantly high odds ratio in females after adjusting for active disease symptom. By stepwise logistic regression analysis, working phase and mental phase in males, economic phase and mental phase in females were shown to be significant. Improvement of quality of life including mental phase and working phase appear to raise the life satisfaction in Behçet's disease patients.

[Effectiveness of magnetic resonance angiography for mass screening of unruptured intracranial aneurysms].

Magnetic resonance angiography (MRA) is widely used in screening for unruptured intracranial aneurysm (UIA) in the prevention of onset of subarachnoid hemorrhage (SAH) in Japan. However, the clinical efficacy of mass screening of UIA using MRA has not been established. This study aims to establish the clinical efficacy of mass screening of UIA using MRA by decision-making. The decision tree is constructed simulating a flow of population (100,000 persons, aged 50-59) starting from the MRA screening until the final outcomes of quality adjusted life or death in ten years. In order to estimate the numerical values various parameters were used as follows, prevalence rate: 1%; sensitivity of MRA: 74%; specificity of MRA: 76%; death rate by intracranial angiography: 0.1%; rupture rate of UIA: 2%/year; death rate of SAH: 57%; and death rate for surgery for UIA: 0.0%. The following results were obtained: 1. The number of lives saved by the MRA screening was 760, while the number saved without MRA was 79. 2. The number of deaths in those receiving the MRA screening was 52, while the number of deaths without MRA was 104. 3. The level of quality adjusted life with the MRA screening was higher than that without MRA in all cases. In conclusion, mass screening of UIA using MRA appears to be effective.

Years of potential life lost as the indicator of premature mortality in occupational medicine.

Measurement of premature mortality is necessary to plan medical programs and to conduct effective medical activities. The purpose of this study was to compare the years of potential life lost (YPLL) with other mortality indices and to understand the usefulness and limitations of quantitative measurement for premature mortality. Data concerning death during employment were surveyed from 1979 to 1984. One thousand seven hundred twenty-five deaths were observed in 1,504,462 person-years in the study population. Proportionate mortality ratios indicated medical problems concerning malignant neoplasms and heart disease, but they could not identify the problems of suicide and traffic accidents occurring in the relatively younger group. YPLL by a constant end point at 60 years of age could rank these causes next below the major leading causes of death. Thus, YPLL might be a useful indicator of the problems concerning premature mortality in occupational medicine.

Influence of Behavioral and Environmental Factors on the Development of Obesity in Three-year-old Children -A Case-Control Study Based on Toyama Study-.

Obesity in children seems to be a risk factor for chronic diseases in adulthood. From the viewpoint of preventive medicine, factors influencing the development of obese children should be removed early in life.The purpose of this study was to the elucidate relationship between obesity in 3-year-old children and both behavioral and environmental factors by conducting a case-control study. Subjects were selected from the Toyama study. Matched-pair comparisons were performed between obese children whose Kaup's index was 18 or more (N=117) and control children (N=234) . Multivariate stepwised logistic regression analysis also applied to assess influence of confounding factors.The results indicated that the following 6 factors significantly influenced the development of obese 3-year-old children in exact Fisher's method analysis (p<0.05): person other than the mother responsible for taking care of the child, short sleep duration (9 hours or less), physical inactivity, eating snacks irregularly, overweight father (BMI≥24), and overweight mother (BMI≥24). For both sexes, after adjusting for confounders by multivariate stepwise logistic analysis, overweight mother (OR 2.54, 95 % CI 1.64-3.95), birth overweight (birth weight≥3,500g; OR 1.76, 95 % CI 1.15-2.69), the mother not responsible for taking care of the child (OR 1.65, 95% CI 1.10-2.48), overweight father (OR 1.62, 95%CI 1.09-2.40), eating snacks irregularly (OR 1.56, 95% CI 1.04-2.33), and gender (female;OR 0.51, 95% CI 0.34-0.77) had significant relationships with obesity in childhood. For boys, overweight mother (OR 2.53, 95 % CI 1.47-4.35), birth overweight (OR 2.03, 95%CI 1.22-3.39), eating snacks irregularly (OR 1.94, 95 %CI 1.19-3.18), and birth month (36-41 months; OR 0.47, 95 % CI 0.23-0.96) had significant relationships. For girls, overweight mother (OR 2.62, 1.28-5.35), and short sleep duration (OR 2.24, 1.11-4.52) had significant relationships. In neither Fisher's exact method nor multivariate logistic models, time to wake up, bedtime, duration of playing outdoors, regularity of meals, care about salty food, or frequency of eating snacks had significant relations with obesity in 3-year-old children (p<0.05).

Family History of Breast Cancer and Breast Cancer Risk in Japan.

We studied 132 families with a family history of breast cancer (familial aggregation cases, FA cases) to assess the breast cancer risk presented by such a family history. For comparison with these FA cases, we randomly selected 132 control families of sporadic cases (SP controls) by adjusting for the age of the proband at surgery. Information on family history was collected for all first-degree female relatives and maternal and paternal grandmothers. Japanese women with a first-degree relative affected by breast cancer were found to have an increased risk of the disease. The odds ratio (OR) for women with a family history of breast cancer was 1.99 (95% confidence interval [ CI ], 1.48-2.66). The OR for FA-case doughters of women with breast cancer was 1.54 (95% CI, 0.91-2.63). A higher risk was not observed if a woman's mother had breast cancer. If the proband had a sister with breast cancer, a slightly increased risk of other cancers of the proband was observed (OR, 1.85 [ 0.87-3.92]). These results suggest that a family history of breast cancer in Japanese women may affect their risk of developing cancer of the breast and other organs.

[Significance of high normal blood pressure in occupational health care].

In order to elucidate the significance of high normal blood pressure in occupational health care, a 5 year follow up survey was performed on 874 men with normal blood pressure and 225 men with high normal blood pressure. The major results of this survey were as follows. 1) Sixty-seven out of 874 with normal blood pressure (7.7%), and 78 out of 225 with high normal blood pressure (34.6%) became hypertensive in 5 years. 2) High normals started with a higher frequency of obesity, hypercholesterolemia, hyper gamma-Glutamyl transpeptidasemia compared with normal blood pressure at the start of the survey. 3) Logistic regression analysis showed that age, SBP, DBP were risk factors of developing hypertension from normal blood pressure, while only the amount of alcohol drinking applied for high normal blood pressure. 4) Logistic regression showed that high normal blood pressure, drinking, obesity and were significantly related to the development of hypertension. These results suggested that interventive activities for high normal blood pressure should be included in occupational health care because of a high tendency of underlying poor life style and a high risk of getting hypertension.

[Long-term analysis of hypertension in men by job type].

Health education intervention for hypertension require the assessment of hypertension. Risk factors for developing hypertension in Japanese workers were evaluated by the type of occupation: manager, office worker, salesperson, blue-collar worker, and engineer. A cohort of 2,257 male subjects, aged 21 through 63 years, who were normotensive, diastolic blood pressure less than 90 mm Hg and systolic blood pressure less than 140 mm Hg in the initial year, were followed for 15 years to observe the occurrence of hypertension. Hypertension was defined as a systolic blood pressure (SBP) of 160 mm Hg or higher and/or a diastolic blood pressure (DBP) of 95 mm Hg or higher, or the initiation of antihypertensive therapy. Eight risk factors related to hypertension (age, body mass index, cigarette smoking, job characteristic, alcohol consumption, stress, SBP, and DBP) were selected for analysis using Cox proportional hazards models. Stepwise model was utilized to incorporate risk factors for each type of occupation (p < 0.05). The following results were obtained: 1. The incidence of hypertension over 15-year analysis was 29.3% for the total male subjects. 2. Each type of occupation had a different pattern of risk factors for hypertension. 3. Blood pressure at baseline showed a significant association in all types of occupation, indicating a stronger relationship with hypertension than other factors. 4. Stress and age were significantly associated in managers, salespersons, and blue-collar workers. 5. Body mass index and alcohol consumption were significantly associated in salespersons. 6. Cigarette smoking was significant in managers and blue-collar workers, with the hazard ratio in managers being greater than 1 (1.66, 95%CI 1.06-2.60) but less than 1 in blue-collar workers (0.31, 95%CI 0.15-0.67). 7. In all types of occupation, job characteristic failed to reach statistical significance. Work-site primary prevention of hypertension should be performed specifically considering type of occupation. Individual risk assessment and lifestyle modification are potentially important tools for health education in the work-site and by applying this model to primary preventive care, appropriate preventive activities specific to an individual may be developed and provided.

An indicator quantitatively comparing two treatment effect sizes on responder and non-responder groups--exponential of estimated interaction parameter.

Sometimes a specific treatment is effective in one subgroup but not in another. An indicator allowing quantitative comparison of treatment effect in two subgroups would be useful in clinical medicine. We have developed such an indicator. It is obtained by calculations using Cox's proportional hazard or logistic model with therapy, subgroup, and confounding explanatory variables. The parameter of the interaction between therapy and subgroup can be estimated and tested statistically. The exponential value of the interaction parameter is what we tentatively call the "hazard ratio ratio", meaning the ratio between the treatment effects in two subgroups. The 95% confidence interval of the indicator can also be calculated. As a numerical example, the hazard ratio between the survival times of postoperative gastric cancer patients treated by adjuvant immunochemotherapy and patients without adjuvant immunochemotherapy in a subgroup with high serum glycosidically bound sialic acid (SA) level was lower than that in a low-SA subgroup using an estimate for hazard ratio ratio of less than 0.5 with statistical significance. We propose this indicator be used as a "responder/non-responder ratio" of therapy effect.

[Health appraisal for work adjustment of freshmen employees--information on health checkup just after entering the corporation and condition in the next fiscal year].

In 1990, 365 (males: 197, females: 168) freshmen employees at the headquarters of a large corporation were examined just after being hired in order to observe their health status. We collected (1) data of physical examinations and questionnaires for symptoms as an ordinary health checkup, (2) information on work adjustment, life patterns, and personal characteristics through interviews conducted by ten public health nurses, and (3) personal records, e.g. birth year. Statistical analyses revealed some notable findings as follows: (1) subjects with higher blood pressure had higher scores of extrovert personality among males, (2) female subjects with greater body mass index had higher scores in such manifestations of personal characteristics such as aggression and discontent with superiors, (3) higher scores of personal characteristics were noted among female subjects working in technical sections, (4) positive correlation between the scores of work adjustment and personal characteristics, (5) higher scores of undesirable life patterns among males and of work maladjustment among elder females, (6) unbalanced meal quality of subjects from rural areas, (7) higher mental tension among younger males from rural areas, and (8) higher scores of dependency and lower morale among younger female subjects. Information on health problems was collected over the 1.5 yrs that followed. More problems were detected among females than among males and among younger females than among elder females. Longitudinal analysis was carried out from just after entry into the company for approximately 1.5 yrs. Health problems in females could be predicted by the data on personal characteristics and work adjustment just after entry. Risk of health problems in male freshmen employees with hobbies and unhealthy drinking habits over the 1.5 yrs that followed was higher than in others. It was concluded that a health interview for freshmen employees by public health nurses is valuable for health care, obtaining information regarding work adjustment, life patterns, and personal characteristics.

Structured neural network of medical diagnosis for hepatobiliary diseases.

This study aims to apply a structured neural network system for improving diagnostic capabilities of hepatobiliary diseases. Several neural networks were organized according to a priori knowledge. A priori knowledge consists of five pathological states. We compared the diagnostic accuracy of discriminant function, ordinary and structured neural networks. The diagnostic capabilities among testing data were 96% by structured neural network, 70% by ordinary neural network, and 66% by discriminant function. The structured neural network had the significantly higher diagnostic accuracy than the other two methods.

Protocol care for hypertension supported by an expert system.

1. PURPOSE. Hypertension if one of the major prevalent diseases that influences the prognosis of chronic diseases. Primary care should attract much attention in the management of hypertension. The management of hypertension includes not only the use of antihypertensiove drugs, but also the modification of unhealthy lifestyles. Multi-dimensional approaches are required for the management of hypertensive patients. This system supports the standard protocol care for hypertensive patients and the database for clinical epidemiology. 2. DESIGN CONSIDERATIONS. This system has several functions that support the appropriate management of hypertensive patients. The first one is clinical database management. The second is the evaluation of the clinical conditions in hypertension. The third is the decision support system for the selection of treatments for hypertension. 3. SYSTEM DESCRIPTION. This system administers the clinical database, which includes symptoms and signs, laboratory data, and prescriptions. The database deals with the temporal course of the patient's status. The system that evaluates the patient's condition and the decision support system have some knowledge bases. The knowledge bases consist of the evaluation of the patient's condition, the appropriate selection of laboratory examinations, and suggestions for treatments, which involve a life-style modification and the proper prescription of medication. 4. STATUS REPORTS. The relational database was developed for handling the patient's records. These records were displayed on the terminal according to the temporal sequence. The graphical representations of the medical data were displayed in order to understand the patient's status. 5. LESSON LEARNED. This kind of protocol care system is expected to support the proper medical care of patients. Excess medications and laboratory examinations will be excluded under the protocol care, thus reducing unnecessary medical expense. The system will enhance the randomized clinical trials that verify the effects of the treatments. Violation of the protocol care is treated according to the several levels. 6. FUTURE PLANS. This system will be introduced to the occupational health care fields. The efficacy of improving the clinical quantity, and the effect of reducing the medical budget concerning hypertension will be verified.