concept
Diabetes is characterized by chronic hyperglycemia due to lack of insulin action and is a group of diseases accompanying various metabolic abnormalities. Due to persistence of long-term hyperglycemia etc., complications specific to diabetes (three major complications (diabetic retinopathy, nephropathy, neuropathy, etc.), etc.), arteriosclerosis and other complications may be caused. Currently it is increasing in Japan, with about 8.9 million people suspected strongly of diabetes and 22 million people estimated to be combined with those who can not deny diabetes. There are about 3,000 people (2nd place of cause of blindness in adults) in one year due to diabetes, about 16,000 people introduce dialysis (first place of dialysis cause), hands and feet It is estimated that there are several thousand people to cut. Furthermore, it is known that cerebral infarction and myocardial infarction are also liable to occur threefold when diabetes is present, and the course after onset is also bad.


Symptom
Symptoms such as dry mouth, polydipsia, polyuria, and weight loss appear if it gets worse, but there are also cases where there is no subjective symptom. Sometimes it is diagnosed as diabetic by visiting a hospital with symptoms due to complications (eg abnormal appearance).

Cause
In addition to inheritance (the constitution born with it), type 2 diabetes which develops with lifestyle affects accounts for nearly 90%. In addition to this, type 1 diabetes, in which insulin secretion is rapidly depleted due to autoimmune etc., diabetes that develops with other diseases, diabetes related to pregnancy, and so on.

Inspection for diagnosis
The normal value of blood glucose is less than 110 mg / dl on an empty stomach. Diabetes is strongly suspected in cases of fasting blood glucose level of 126 mg / dl or more, blood glucose level as occasionally (regardless of meals) 200 mg / dl or more, HbA 1 c 6.5% or more, It may be diagnosed by 75 g oral glucose tolerance test.

Treatment
There are life therapy (diet therapy, exercise therapy, smoking cessation, drinking to keep an appropriate amount, etc.) and medication therapy (internal medicine, injection drug (insulin preparation, GLP-1 analog preparation)).

prevention
Diet therapy is the foundation of prevention and treatment of diabetes. Although it is basic to not eat too much over the appropriate amount (optimization of total calories), it is also important to ingest the necessary nutrients balancedly as daily nutrition. Generally avoid excess of salt and alcohol, vegetables and dietary fiber intends to ingest enough.
Recently "saccharide restricted diet" may become a topic. A good effect can be expected for those who eat too much every day, such as "to refrain from sweet things" "to moderate rice". However, diet therapy that restricts carbohydrates (carbohydrates) extremely and supplements calories with other (fat and protein) is currently not recommended by the Japanese Diabetes Society from the aspect of safety. Compared to the 1960s, when diabetes was still few in Japan, the intake of total calories and carbohydrates gradually decreased, while the intake of fat has increased greatly. At that time, it seems that the intake of rice per capita was about twice as much as the current amount and the intake of fat was about half. It seems that the Japanese staple food has changed from rice to bread, men and others, and has begun to like butter, lipids, dairy products (so-called Western-style meals). At that time, it should be noted that the intake of dietary fiber such as millet, root vegetable and so forth was larger (about 1.4 times) than the present amount (thought to be) (thought to be) (thought to be) a large amount of physical activity, but the investigation of Japanese who moved to Western Europe It is also known that diabetes is seen at a high rate. There seems to be a hint of "diet for prevention of diabetes" among these.

concept
Metabolic syndrome is a condition in which arteriosclerotic diseases such as visceral obesity, insulin resistance / hyperglycemia, abnormal lipid metabolism, rise in blood pressure and the risk of developing type 2 diabetes are accumulated personally. Even if it seemingly does not seem to be an illness or abnormality slightly exceeding the normal value, if it accumulates in an individual, the above risk factor (the risk of cardiovascular disease onset and cardiovascular death is 1.5 to 2 Twice, the risk of developing type 2 diabetes increases 3 to 6 times). Originally it has been proposed as a risk factor other than LDL (bad) cholesterol known as a risk factor for coronary artery disease, so LDL cholesterol is not included in the diagnostic criteria. Hypertension, diabetes, dyslipidemia and obesity are also risk factors for atherosclerotic diseases (eg, about 3 times for diabetes and about 2 times for borderline diabetes mellitus), and these are "slightly abnormal" If you are staying in the treatment area, you need to take more seriously and deal with it.


Symptom
Abdominal girth, blood pressure, etc. can be measured by self, but there is generally no subjective symptom.

Cause
Obesity (especially visceral obesity) is thought to play a central role. Adipocytes are known not only to store fat but also to emit various bad substance. It is also known that obesity not only metabolic syndrome but also many diseases merge.

Inspection for diagnosis
The waist perimeter (abdominal circumference) is 85 cm or more in men and 90 cm or more in females, and it is diagnosed as metabolic syndrome if it falls into two or more of the following three items.

Neutral fat (fasting) 150 mg / dl or more and / or
HDL cholesterol less than 40 mg / dl
Systolic blood pressure of 130 mmHg or more and / or diastolic blood pressure of 85 mmHg or more
Fasting blood glucose 110 mg / dl or more
(In case of drug being treated already, treat it even if it is below the reference value)
Treatment and Prevention
As for metabolic syndrome, obesity plays a central role, so it is important to maintain proper weight in diet therapy, exercise therapy and other life therapy. In addition, smoking cessation is extremely important in preventing arteriosclerosis.
In addition, when it is pointed out at medical examinations etc., there are many cases that it is a merger of hypertension, diabetes (or border type diabetes), dyslipidemia (including high LDLemia) rather than metabolic syndrome. As mentioned above, in this case it is necessary to tackle treatment with further medical knowledge.

What is a stroke?
Stroke includes ① cerebral infarction, ② cerebral hemorrhage, ③ subarachnoid hemorrhage (Figure 1). Cerebral infarction is a disease in which the brain is necrotized by clogging of blood vessels in the brain. It is said that 10 to 20% (half within 48 hours) of stroke cerebral ischemic attack (symptoms disappear within 24 hours), which is a prelude to cerebral infarction, causes cerebral infarction in 3 months , We will investigate the cause and prevent cerebral infarction.
Cerebral haemorrhage occurs when small blood vessels in the brain are broken, but many are said to be hypertensive cerebral hemorrhage due to high blood pressure. It is possible to prevent lifestyle habits that will not result in hypertension, or to treat high blood pressure. A lot of alcohol drinking is also a cause.
Subarachnoid hemorrhage occurs in ruptured cerebral aneurysms or bleeding from cerebral vessel malformations. Subarachnoid hemorrhage is more likely to occur when smoking, drinking alcohol, or hypertension is present.


Symptoms of stroke
There are five symptoms of stroke: ① sudden half body weakness / numbness, ② sudden speech disorder / consciousness disturbance, ③ sudden vision disorder, ④ sudden dizziness · wobble · walking disturbance, ⑤ sudden severe headache. A sudden, severe headache is a symptom suspected of subarachnoid hemorrhage. If you have symptoms of stroke, please consult a special hospital immediately.
In case of suspicion of stroke, ① face (whether there is no left or right difference in smiling face), ② arm (tilting his eyes with the palm facing up and putting both arms horizontally, one side arm falls 3) Please check the three points (___ ___ ___ 0 ___ ___ 0 ___ ___ 0 ___ ___ 0 ___ ___ 0 , Arm, Speech, Time: "Visit immediately with face, arms, words"). If there is a sudden symptom, if there is one of these, the probability of stroke is said to be about 70%.

Causes of cerebral infarction (Figure 2)
Many strokes are lifestyle diseases. Figure 2 shows the progress and measures of lifestyle-related diseases. ① inappropriate lifestyle, ② border area, ③ lifestyle diseases as a risk factor, ④ lifestyle diseases as a disease (including cerebral infarction) ⑤ need for long-term care (bedridden and dementia) We will progress in the form, for example. Arrhythmia called atrial fibrillation causes cerebral infarction, in which case it causes the most severe cardiogenic cerebral embolism in cerebral infarction.
Lifestyle such as eating habits, exercise habits, resting habits (rest and sleep), taste habits (smoking, drinking) etc can be modified. There are also lifestyle diseases such as hypertension, diabetes, dyslipidemia, obesity, metabolic syndrome, etc. that can be corrected by the risk factors for stroke. As uncorrectable, there are age, sex, race, genetic predisposition and so on.

Arrhythmia and cerebral infarction - Figure 2
Inspection for cerebral infarction
Cerebral infarction includes a lacunar infarct caused by clogging of small blood vessels in the brain (cerebral hemorrhage when this blood vessel breaks), atherothrombotic cerebral infarction caused by narrowing or clogging of large blood vessels in the brain and outside the brain, atrial fibrillation Cardiogenic cerebral embolism caused by heart disease such as movement, and other cerebral infarction caused by special causes (Fig. 1). There are many heart diseases that cause cardiogenic cerebral embolism (Figure 3), but about 90% occurs due to atrial fibrillation.
For cerebral infarction, detection of lesions, evaluation of blood vessels and heart are necessary, and the following tests are performed as necessary.

Prevention of recurrence of cerebral infarction
Figure 7 shows the recurrence rate of cerebral infarction. Although 10% in 1 year and 50% in 10 years will recur, cardiogenic cerebral embolism caused by atrial fibrillation is 75.2% in 10 years, the highest rate of recurrence among cerebral infarction is.
Prevention of recurrence is started with treatment of acute stage immediately after onset (drip and drinking medicine). Figure 8 shows the strategy for preventing recurrence of cerebral infarction. Smoking cessation, salt reduction, weight loss (maintenance of proper weight by diet therapy and exercise therapy) · Modification of lifestyle such as sake, etc., drug treatment for hypertension · diabetes · dyslipidemia · atrial fibrillation · nicotine addiction etc. to hold. We will also prevent recurrence by antiplatelet drugs for lacunar infarction and atherothrombotic cerebral infarction, and anticoagulants for cardiogenic cerebral embolism. Some patients have surgical treatment and intravascular treatment.
For cardiogenic cerebral embolism caused by atrial fibrillation, an anticoagulant is needed to prevent thrombus formation in the heart (Fig. 9). Figure 10 shows an oral anticoagulant for preventing the onset and recurrence of cardiogenic cerebral embolism in atrial fibrillation. Warfarin (Warfarin Ⓡ) is prohibited from ingesting natto, chlorella, blue juice, moroheiya etc, but dabigatran etexilate (plazaxa Ⓡ), river rosaban (exazalto Ⓡ), apixaban (erythrose Ⓡ), edoxaban ) Can be ingested with new oral anticoagulants. Figure 10 shows the 10 strokes of the
Japan Stroke Association overcome the stroke.


Rehabilitation of cerebral infarction includes physical therapy, occupational therapy, speech therapy, psychotherapy. These rehabilitations are acute phase hospitals (emergency hospitals), recovery period (after 1 to 3 weeks after onset) are specialized hospitals for rehabilitation, maintenance period (after 3 to 6 months from onset) is home, facilities, sanatorial hospitals .

Prevention of cerebral infarction
In prevention of cerebral infarction, countermeasures will be different depending on progress of lifestyle diseases (Figure 2). Those with high frequency of cerebral infarction are ① hypertension, ② diabetes, ③ atrial fibrillation, ④ smoking, ⑤ dyslipidemia. On the other hand, smoking is the most effective way to prevent cerebral infarction, maintenance of ideal weight and exercise are also important (Figure 13). Please certainly combine these treatments and practice diversification management while consulting with your doctor's doctor. There is no treatment superior to prevention. Moreover , I think that you should bear in mind the 10 th stroke prevention clause created by the Japan Stroke Association (Fig. 14). Health Japan 21 recommends taking 350 g of vegetables a day. In addition, as the target value of the number of steps by everyday life, it shows 9,200 male adult males, 8,300 female females, 6,700 men of elderly men and 5,900 female females.
Please practice "1 to exercise, 2 to meal, firm smoking cessation, finally medicine".

Alcohol · obesity and liver disease
Alcoholic liver injury is a hepatic disorder caused by more than 3 consecutive drinking a day, various diseases appear. It develops when abdominal pain, fever, jaundice becomes severe, but it is a disease that has many opportunities to be found by elevation of liver function (AST, ALT, γ-GTP) in health examination etc. Allergic vulnerable people (aldehyde dehydrogenase 2 activity deficient) or women may experience alcoholic liver damage even at about 2 times a day.


Obesity also causes fat deposits in the liver, and as it is often heard, it shows the state of fatty liver. Alcoholic liver injury also presents the pathology of alcoholic fatty liver in the early stages. Diagnosis is possible by abdominal ultrasonography and blood test at this time. Also at this time, abstinence will improve ultrasonic findings and abnormal values ​​of blood test promptly.

　Alcoholic liver damage also remains unchanged, as alcohol consumption increases, ballooning of hepatocytes takes place, and if you can not drink alcohol you will be transferred to liver cirrhosis. Serious conditions such as hepatic encephalopathy, gastrointestinal bleeding, acute renal failure and other serious conditions are caused.

　If more than 3 consecutive habitual drinking or more than 5 consecutive drinks continue, fibrosis occurs in the liver and progresses from alcoholic liver fibrosis to alcoholic cirrhosis. When liver cirrhosis develops, jaundice, ascites, hepatic encephalopathy etc. appear, and the quality of life (QOL) declines.

　Basis of treatment is abstinence, other therapies are ancillary to the last, not very effective. To abstain from alcohol is very difficult and requires a solid determination of the person and warm watchful observation of the surroundings. For regular drinkers, it is necessary to increase opportunities to save and make efforts to reduce as much as 3 days a day as much as possible.

　Obesity, along with alcohol, is not very good for the liver. When triglyceride accumulates in hepatocytes, if it accumulates in more than 1/3 of the liver, it becomes a pathology of fatty liver. In ultrasonography, fat deposited in hepatocytes is depicted as a high echo and looks brighter white than the kidneys (bright liver).

　As fatty liver also progresses, it progresses from steatohepatitis to liver cirrhosis, so it can not be tolerated. Fatty liver is reversible, can be improved by abstinence, weight loss and exercise.

Although weight reduction, diet therapy, restriction of alcohol, etc. are all serious, it is more important than ever to strive hard. Since obesity and alcohol have synergistic effects, if one improves, the other will also improve, so it is considered a secret of success to achieve the goal with family and friends.

Laryngeal cancer

Head and neck cancers focused on otolaryngology are thought to be about 5% of all cancers, but they include lips and oral cancer, nasal and sinus cancer, nasopharyngeal cancer, oropharynx Cancer, hypopharyngeal cancer, laryngeal cancer, salivary gland carcinoma, thyroid carcinoma · · ·, and so on. Among them, occupying about 30%, the most frequent occurrence is laryngeal cancer. Recent statistics are about 3 to 4 people per 100 thousand population, men have smoking history more than 10 times and more than 90% of women, and are representatives of tobacco-related cancer.



Conversely, if you do not smoke it will be almost a cancer that will not be affected, but people who have a lot of opportunities to passive smoking also need attention. It is also known that cancers in the upper gastrointestinal tract are likely to be duplicated, as with other head and neck cancers.
Laryngeal cancer is divided into glottic cancers that can be made in the vocal cords, glottic tops that can be made on the mouth side than that, and vocal canards that can be made on the trachea side. Percentage is about 60% of glottic cancers and about 50% of glottic cancers About 30%, the occurrence of subgroup cancer is slight. It is a transnasal endoscope photograph of each. Since vocal cords produce voices by vibrations of the left and right vocal cords, glottic cancers are diagnosed at an early stage and often diagnosed, but on glottic tops, it progresses relatively, and pain and swelling of the throat when feeling swallowed It is often found after the symptoms such as the swelling of the lymph nodes that metastasized to the neck is the initial symptom. I do not have symptoms until GOOM further progress, so it is an impression that often breathing difficulties have already come at the time of consultation. (It is hard to understand in the photograph because it is developing on the back of the vocal cord, but there is actually a considerable spreading.) Tracheotomy is necessary for breathing difficulties. If there is abnormality like a photograph at the outpatient visit, we pick up the tissue on the spot and confirm the diagnosis (It takes about one week.). For diagnosis of progress degree, image inspection such as MRI and CT is performed.


Treatment of laryngeal cancer is performed mainly by surgery or radiotherapy, depending on the progress of the larynx cancer, in a way that combines them with anticancer drug treatment alone or in combination. As shown in the figure the larynx is framed by several cartilage centered on thyroid cartilage and cricoid cartilage which is palpated as a throat Buddha.


As with cancer in other areas, TNM classification detailed in the handling regulations is stipulated for degree of progression, but roughly invasion into this framework or progressive disorder of vocal cords progresses Cancer, those not going to that point may be thought of as early cancer. If lymph node metastasis or distant metastasis occurs in the neck, it will be advanced only. The cure rate of the laryngeal cancer as a whole is 7 to 80%, which is higher in head and neck cancers, but this is often found at an early stage, and even if locally advanced cancer is comparatively metastatic It is because it is few. There is no curative treatment in the case of distant metastasis, anticancer drug treatment and so on according to the situation. In cases where it is limited to lymph node metastasis in the cervical region, it can often be expected that cure can be achieved by treating the primary lesion with treatment based on surgery such as cervical lymphadenectomy. I will describe the treatment of the primary lesion.
In cancer surgery, it is said that curability is high enough to largely cut the tissue around the cancer. However, if such an operation is performed on the laryngeal cancer, there is a problem that it not only hinders speech but also makes it easy to aspirate, so as not to cause these as much as possible, It is important. The most invasive surgery for laryngeal cancer is a total laryngectomy that resects the larynx with the whole frame of the cartilage and can eradicate many cancers but in this case it not only loses the sound source , A hole called a permanent trachea hole is made in the anterior neck for breathing.

As the airway and the esophagus are separated, the risk of aspiration disappears, but there is a danger of drowning due to the action that water can enter the permanent tracheostomy such as bathing, inconvenience comes to life. It still falls under the disabled person. As much as possible, it is not necessary to take out the entire larynx, and it is necessary to select a treatment so that cancer can be cured.

For early cancer, T1 and T2 will be taken from the shallow one, but for these, 8 to 90% of the radiation alone can obtain a cure of 5 to 70%. Although radiotherapy is usually done at hospital, the greatest advantage is that there is no exacerbation of speech. A disadvantage is that there is a risk of complications due to radiation, but it may be that it takes a treatment period of nearly two months. If you do not feel comfortable you need surgery. For surgery for early cancer, there is a technique to remove a portion of the laryngeal framework, but there are many cases to choose laser surgery under a direct mirror that is performed by oral operation without damaging the framework. Although it is difficult to do depending on the extent of the progress of the lesion, the treatment effect is similar to radiotherapy, close to the operation of benign lesions such as vocal cord polyps, and in our department we usually go to hospital for 2 nights and 3 days. The disadvantage is that there is a possibility that the voice may worsen because there are many cases where the vocal cords are excised.

For advanced cancers, it is difficult to cure radiation alone, so we usually use multiple anticancer drugs in combination. Side effects of anticancer drugs often appear strongly, and the control rate is further deteriorated, so surgery will be mainly focused on. Among them, total laryngectomy is often selected, and further enlarged resection is sometimes required, but on the other hand, there is a subtotal laryngectomy as a technique that has been relatively popular in the country recently . It is a method of resecting cancer in a mass with thyroid cartilage which is the center of the laryngeal framework. Completely resected to one side of the arytenoid cartilage is made possible and after a lesion resection, it is a slightly rough seeming operation that severely fixes the hyoid bone and cricoid cartilage, but the greatest advantage is that it does not form a permanent tracheostomy It is a point.
This method was devised and improved in France in the 1950s, but it is said that about 30% of cases that had previously performed a total laryngectomy is subject to this surgery. The problem is that the local edema after surgery becomes stronger, the tracheostomy hole temporarily placed can not be closed easily, it takes time to be able to swallow successfully, so the length of stay in hospital becomes as long as about 2 months (In the case of our department of total laryngectomy, it is within 3 weeks at the shortest.). Also, even if cancer can be cured, it is expected that aspiration will come afterwards, and it seems that sufficient follow-up observation is necessary. For this reason it is not recommended for elderly people.

Although we will lose vocal cords after total laryngectomy, there are several alternative voicing methods such as artificial larynx use and esophageal vocalization. Among them, there is a method that uses a voice button with a one-way valve formed by forming a tracheoesophageal fistula and allowing it to easily acquire relatively good voice. Push your trachea with your fingers and send the expiration toward the oral cavity. There is no intonation voice, but there are people who speak on the phone. Because the voice button gets dirty, it is necessary to change it about once a year in a clinic.
In our department, we have chosen patients to inform patients about the disadvantages of the treatment regimen. In the three years since fiscal 2011, 47 people who underwent treatment in our department, 43 of those who had the initial anticancer treatment, the treatment of the primary tumor was 13 radiation alone therapy, radiation There were 4 chemotherapy, 16 laser surgery, 1 laryngectomy and 9 laryngectomy.