• Journal of the Korean Society of Food Science and Nutrition
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• v.39 no.6
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• pp.894-901
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• 2010

To measure the heavy metal contents of marine invertebrates, we collected 239 individuals representing 52 species from the eastern (Pohang), western (Gunsan), and southern (Tongyeong) coasts of Korea: 34 species of molluscan shellfish (Gastropoda and Bivalvia), 6 species of Cephalopoda, 8 species of Crustacea, and 4 other species. The mean levels of the heavy metals in the samples taken from the edible portion of each Gastropoda were high in the order of Zn ($21.471\;{\mu}g/g$), Cu ($4.115\;{\mu}g/g$), Mn ($0.868\;{\mu}g/g$), Ni ($0.254\;{\mu}g/g$), Pb ($0.238\;{\mu}g/g$), Cd ($0.154\;{\mu}g/g$), and Cr ($0.110\;{\mu}g/g$). The heavy metals in the Bivalvia were high in the order of Zn ($35.655\;{\mu}g/g$), Mn ($5.500\;{\mu}g/g$), Cu ($3.129\;{\mu}g/g$), Cd ($0.423\;{\mu}g/g$), Ni ($0.402\;{\mu}g/g$), Cr ($0.233\;{\mu}g/g$), and Pb ($0.232\;{\mu}g/g$). The heavy metals in the Cephalopoda were high in the order of Zn ($18.380\;{\mu}g/g$), Cu ($3.594\;{\mu}g/g$), Mn ($0.630\;{\mu}g/g$), Cr ($0.150\;{\mu}g/g$), Pb ($0.068\;{\mu}g/g$), Cd ($0.034\;{\mu}g/g$), and Ni ($0.030\;{\mu}g/g$). The heavy metals in the Crustacea were high in the order of Zn ($25.333\;{\mu}g$/g), Cu ($9.042\;{\mu}g/g$), Mn ($0.659\;{\mu}g/g$), Cr ($0.592\;{\mu}g/g$), Cd ($0.207\;{\mu}g/g$), Pb ($0.126\;{\mu}g/g$), and Ni ($0.094\;{\mu}g/g$). Therefore, the mean levels of the harmful heavy metals (Cd and Pb) in marine invertebrates were high in the order of Bivalvia>Crustacea＝Gastropoda>Cephalopoda. The average daily intakes of the heavy metals from the fisheries products were as follows: Cd ($6.88\;{\mu}g$), Cr ($19.13\;{\mu}g$), Cu ($137.02\;{\mu}g$), Mn ($156.13\;{\mu}g$), Ni ($11.39\;{\mu}g$), Pb ($7.01\;{\mu}g$) and Zn ($1,025.94\;{\mu}g$). The average weekly intakes of Cd, Cu, Pb and Zn from the fisheries products were 11.47%, 0.46%, 3.27% and 1.71% respectively, as compared with PTWI (Provisional Tolerable Weekly Intakes) established by FAO/WHO Expert Committee for Food Safety Evaluation.

• KOREAN JOURNAL OF CROP SCIENCE
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• v.18
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• pp.54-87
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• 1975

The effects of various weather factors on yield components of rice, year variation of yield components within regions, and regional differences of yield components within year were investigated at three Crop Experiment Stations O.R.D., Suweon, Iri, Milyang, and at nine provincial Offices of Rural Development for eight years from 1966 to 1973 for the purpose of providing information required in improving cultural practices and predicting the yield level of rice. The experimental results analyzed by standard partial regression analysis are summarized as follows: 1. When rice was grown in ordinary seasonal culture the number of panicles greatly affected rice yield compared to other yield components. However, when rice was seeded in ordinary season and transplanted late, and transplanted in ordinary season in the northern area the ratio of ripening was closely related to the rice yield. 2. The number of panicles showed the greatest year variation when the Jinheung variety was grown in the northern area. The ripening ratio or 1, 000 grain weight also greatly varied due to years. However, the number of spikelets per unit area showed the greatest effects on yield of the Tongil variety. 2. Regional variation of yield components was classified into five groups; 1) Vegetation dependable type (V), 2) Partial vegetation dependable type (P), 3) Medium type (M), 4) Partial ripening dependable type (P.R), and 5) Ripening dependable type (R). In general, the number of kernel of rice in the southern area showed the greatest partial regression coefficient among yield components. However, in the mid-northern part of country the ripening ratio was one of the component!; affecting rice yield most. 4. A multivariate equation was obtained for both normal planting and late planting by log-transforming from the multiplication of each component of four yield components to additive fashion. It revealed that a more accurate yield could be estimated from the above equation in both cases of ordinary seasonal culture and late transplanting. 5. A highly positive correlation coefficient was obtained between the number of tillers from 20 days after transplanting and the number of panicles at each(tillering) stage 20 days after transplanting in normal planting and late planting methods. 6. A close relationship was found between the number of panicles and weather factors 21 to 30 days, after transplanting. 7. The average temperature 31 to 40 days after transplanting was greatly responsible for the maximum number of tillers while the number of duration of sunshine hours per day 11 to 30 days after transplantation was responsible for that character. The effect of water temperature was negligible. 8. No reasonable prediction for number of panicles was calculated from using either number of tillers or climatic factors. The number of panicles could early be estimated formulating a multiple equation using number of tillers 20 days after transplantation and maximum temperature, temperature range and duration of sunshine for the period of 20 days from 20 to 40 days after transplantation. 9. The effects of maximum temperature and day length 25 to 34 days before heading, on kernel number per panicle, were great in the mid-northern area. However, the minimum temperature and day length greatly affected the kernel number per panicle in the southern area. The maximum temperature had a negative relationship with the kernel number per panicle in the southern area. 10. The maximum temperature was highly responsible for an increased ripening ratio. On the other hand, the minimum temperature at pre-heading and early ripening stages showed an adverse effect on ripening ratio. 11. The 1, 000 grain weight was greatly affected by the maximum temperature during pre- or mid-ripening stage and was negatively associated with the minimum temperature over the entire ripening period.

• Journal of agricultural medicine and community health
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• v.29 no.1
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• pp.65-75
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• 2004

Objectives: Immunizations have been one of the most effective measures preventing from infectious diseases. It is quite important national infectious disease prevention policy to keep the immunizations rate high and monitor the immunizations rate continuously. To do this, Korean CDC introduced the National Immunization Registry Program(NIRP) which has been implementing since 2000 at the Public Health Centers(PHC). The National Immunization Registry Program will be near completed after sharing, connecting and transfering vaccination data between public and private sector. The aims of this study was to evaluate the immunization module of non-chart system in private clinic with health information system of public health center(made by POSDATA Co., LTD) and immunization registry program(made by BIT Computer Co., LTD). Methods: The analysis and survey were done by specialists in medical, health field, and health information fields from 2001. November to 2002. January. We made the analysis and recommendation about the immunization module of non-chart system in private clinic. Results and Conclusions: To make improvement on immunization module, the system will be revised on various function like receipt and registration, preliminary medical examination, reference and inquiry, registration of vaccine, print-out various sheet, function of transfer vaccination data, issue function of vaccination certification, function of reminder and recall, function of statistical calculation, and management of vaccine stock. There are needs of an accurate assessment of current immunization module on each private non-chart system. And further studies will be necessary to make it an accurate system under changing health policy related national immunization program. We hope that the result of this study may contribute to establish the National Immunization Registry Program.

• Progress in Medical Physics
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• v.23 no.1
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• pp.15-25
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• 2012

The aim of this study is to evaluate plan quality and dose accuracy for Volumetric Modulated Arc Therapy (VMAT) on the TG-119 and is to investigate the effects on variation of the selectable optimization parameters of VMAT. VMAT treatment planning was implemented on a Varian iX linear accelerator with ARIA record and verify system (Varian Mecical System Palo Alto, CA) and Oncentra MasterPlan treatment planning system (Nucletron BV, Veenendaal, Netherlands). Plan quality and dosimetric accuracy were evaluated by effect of varying a number of arc, gantry spacing and delivery time for the test geometries provided in TG-119. Plan quality for the target and OAR was evaluated by the mean value and the standard deviation of the Dose Volume Histograms (DVHs). The ionization chamber and $Delta^{4PT}$ bi-planar diode array were used for the dose evaluation. For treatment planning evaluation, all structure sets closed to the goals in the case of single arc, except for the C-shape (hard), and all structure sets achieved the goals in the case of dual arc, except for C-shape (hard). For the variation of a number of arc, the simple structure such as a prostate did not have the difference between single arc and dual arc, whereas the complex structure such as a head and neck showed a superior result in the case of dual arc. The dose distribution with gantry spacing of $4^{\circ}$ was shown better plan quality than the gantry spacing of $6^{\circ}$, but was similar results compared with gantry spacing of $2^{\circ}$. For the verification of dose accuracy with single arc and dual arc, the mean value of a relative error between measured and calculated value were within 3% and 4% for point dose and confidence limit values, respectively. For the verification on dose accuracy with the gantry intervals of $2^{\circ}$, $4^{\circ}$ and $6^{\circ}$, the mean values of relative error were within 3% and 5% for point dose and confidence limit values, respectively. In the verification of dose distribution with $Delta^{4PT}$ bi-planar diode array, gamma passing rate was $98.72{\pm}1.52%$ and $98.3{\pm}1.5%$ for single arc and dual arc, respectively. The confidence limit values were within 4%. The smaller the gantry spacing, the more accuracy results were shown. In this study, we performed the VMAT QA based on TG-119 procedure, and demonstrated that all structure sets were satisfied with acceptance criteria. And also, the results for the selective optimization variables informed the importance of selection for the suitable variables according to the clinical cases.

• The Korean Journal of Nuclear Medicine
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• v.37 no.2
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• pp.83-93
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• 2003

Background: Lung-to-heart uptake ratio (LHR) in $^{201}Tl-chloride$ myocardial perfusion scan is believed to be a reliable marker for left ventricular (LV) dysfunction, but the clinical value of LHR is controversial for $^{99m}Tc-MIBI$ imaging. Furthermore, most of results suggesting lung uptake of $^{99m}Tc-MIBI$ as a potential marker for LV dysfunction used immediate post-stress images, instead of routine images acquired 1 hour after tracer injection. The goal of our study was to investigate whether LHR evaluated with routine gated $^{99m}Tc-MIBI$ imaging can reflect the degree of perfusion defect or left ventricular performance. Subjects and Methods: 241 patients underwent exercise $^{99m}Tc-MIBI$ myocardial SPECT were classified into normal myocardial perfusion (NP, n=135) and abnormal myocardial perfusion (AP, n=106) group according to the presence of perfusion defect. LHR was calculated from anterior projection image taken at 1-hour after injection. Two legions of interest (ROIs) were placed on left lung above LV and on myocardium showing the highest radioactivity. Subjects were classified by left ventricular ejection fraction (LVEF), as Gr-I: >50%, Gr-II: 36-50%, Gr-III: <36% and by summed stress score (SSS), as Gr-A: <4, Gr-B: 4-8, Gr-C: 9-13, Gr-D: >13, LHR was compared among these groups. Results: In NP group(n=135), LHR, were higher in men than women ($men:\;0.311{\pm}0.03,\;women:\;0.296{\pm}0.03,\;p<0.05$). Significant difference, in LHR were found between NP and AP groups both for men and women ($men:\;0.311{\pm}0.03\;vs\;.\;0.331{\pm}0.06,\;women:\;0.296{\pm}0.03\;vs.\;0.321{\pm}0.07.\;p<0.05$). There were weak negative correlation between LHR and LVEF (r=-0.342, p<0.05) and weak positive correlation between LHR and SSS (r=0.478, p<0.05) in men, but not in women (LVEF: r=-0.279, p=0.100, SSS: r=0.276, p=0.103). Increased LHR was defined when for more than mean + 2SD value ($men{\geq}0.38,\;women{\geq}0.37$) of the LHR of the subject with normal perfusion. Increased LHR were observed more frequently in subjects with lower LVEF (Gr-I: 11.1%, Gr-II: 27.0%, Gr-III: 35.4%, p<0.05) and higher SSS(Gr-A: 14.0%, Gr-B: 5.7%, Gr-C: 18.2%, Gr-D: 40.7%, p<0.05). Conclusions: LHRs obtained from routine $^{99m}Tc-MIBI$ gated SPECT images were weakly correlated with LVEF and perfusion defect. Although significant overlaps were observed between normal and abnormal perfusion group, LHRs could be used as an indirect marker of severe perfusion defect or reduced left ventricular function.

• The Journal of the Petrological Society of Korea
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• v.12 no.3
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• pp.119-134
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• 2003

Yuksipryeong two-mica granite presents strongly peraluminous characteristics in both mineralogy and geochemistry. It has high aluminum saturation index with 1.15∼l.20 and high corundum with 2.20∼2.98 wt% CIPW norm. As the color index is <16% and FeO$\^$T/+ MgO + TiO$_2$is average 1.9 wt％, it corresponds to leucogranite. Yuksipryeong two-mica leucogranite shows negative linear trend for TiO$_2$, Al$_2$O$_3$, FeO, Fe$_2$O$_3$, MgO, CaO, K$_2$O, P$_2$O$\_$5/, Rb, Ba, and Sr as SiO$_2$increases, and the positive relation of Zr and Th, which result from feldspar, biotite, apatite and zircon fractionation. Pegmatitic dike has higher SiO$_2$and P$_2$O$\_$5/, but lower another major elements. Yuksipryeong two-mica leucogranite has lower Rb, but higher Ba and Sr than Manaslu, Hercynian two-mica leucogranites, and S-type granites in Lachlan Fold Belt. Pegmatitic dike has higher Rb and Nb but lower Ba, Sr, Zr, Th, and Pb contents than Yuksipryeong two-mica leucogranite, resulting in removing or mobilizing for some trace elements from the granitic melt. Yuksipryeong two-mica leucogranite has total REEs with 95.7∼l23.3 ppm, and chondrite-normalized REE pattern is very steep ((La/Yb)$\_$N/ = 6.9∼24.8), light REEs (LREEs)-enriched End heavy REEs (HREEs)- depleted pattern with low to moderate Eu anomalies (Eu/Eu＊= 0.7∼0.9). While pegmatitic dike has low total REEs with 7.0 ppm, and chondrite-normalized REE pattern is flat-pattern ((La/Yb)$\_$N/ = 2.1) with strong negative Eu anomalies (Eu/Eu＊= 0.2). The melt compositions having formed two-mica leucogranites depend on not only the source rock but also the amounts of the residual remaining after melting of source rocks. The CaO/Na$_2$O and Rb/Sr-Rb/Ba ratios depend mainly on the composition of source rocks in the strongly peraluminous granite, that is, plagioclase/clay ratio of the source rocks. Yuksipryeong two-mica leucogranite has higher CaO/Na$_2$O and lower Rb/Sr-Rb/Ba ratios than Manaslu and Hercynian two-mica leucogranites (Millevaches and Gueret) derived from clay-rich, plagioclase-poor (polite), which suggest that the probable source rocks for Yuksipryeong two-mica leucogranite is clay-poor, plagioclase-rich quartzofeldspathic rocks. As the concentrations of Al$_2$O$_3$remain nearly constant but those of TiO$_2$increases as increasing temperature in the strong peraluminous melt, the Al$_2$O$_3$/TiO$_2$ratio may reflect relative temperature at which the melts have formed. Comparing the polite-derived Manaslu and Hercynian two- mica leucogranites, Manaslu two-mica leucogranite has higher Al$_2$O$_3$/TiO$_2$ratio than latter, and its melt have formed at relatively lower temperature ($\leq$ 875$^{\circ}C$) than Hercynian two-mica leucogranites. Likewise, comparing the quartzofeldspathic rock-derived granites, Yuksipryeong two-mica granite has higher Al$_2$O$_3$/TiO$_2$, ratio than S-type granites in Lachlan Fold Belt (>875$^{\circ}C$). The melt formed Yuksipryeong two-mica leucogranite are considered to have been formed at temperature at below the maximum 875$^{\circ}C$C$.

• KOREAN JOURNAL OF CROP SCIENCE
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• v.50 no.spc1
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• pp.152-160
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• 2005

This study was carried out to investigate selectable criteria in evaluating waxy corn $F_1$ hybrids for developing good eating quality waxy corn variety. The physicochemical property analysis of 6 waxy corn $F_1$ hybrids - Chalok1, Chalok2, Heugjeomchal, Yeonnongl, Chalok4, and Suwon45- showed a range of $11.2\~13.1\%$ for crude protein, $5.1\~6.0\%$ for crude fat, $91.8\~92.6\%$ for amylopectin, and $4.5\~6.6\%$ for free sugar content. The pericarp thickness which is one of the most important characteristics related to tenderness in waxy corn was ranged $34\~47{\mu}m$ in 4 waxy corn hybrids - Yeonnongl, Chalok4, Suwon45, and Heugjeomchal. On the other hand, it was ranged $64\~81{\mu}m$ in Chalok1 and Chalok2. The amylogram analysis by rapid visco analyzer showed that in fresh waxy corn hybrid (DAP25), all amylogram properties except setback were higher in Yeonnongl, Chalok4, and Suwon45 compared to those of Chalokl, Chnlok2, and Heugjeomchal. However, in matured waxy corn hybyids (DAP45), the result was the opposite - the amylogram properties were higher in Chalokl, Chalok2, and Heugjeomchal than those of Yeonnongl, Chalok4, and Suwon45. The texture analysis showed that gumminess, chewiness, and hardness increased dramatically with the time after the cooking in Chalokl and Beugjeomchal. On the other hand, these above pyoperties did not change as rapidly with the time in Yeonnongl, Chalok4, and Suwon45. Gumminess, chewiness, and hardness did not increase much within 6 hours after steamingr but increased significantly 32 hours after steaming. Therefore, we have reached a conclusion that texture analysis of cooked waxy corn should be carried out 6 hours after steaming. In the sensory evaluation, Yeonnongl, Chalok4, and Suwon45 revealed higher palatability -6.8, 7.1, and 6.9 respectively - than. that of Chnlokl, Chalok2, and Heugjeomchal. The palatability analysis of 6 waxy corn hybrids showed palatability positively correlating with free sugar content,100-kernel weight, kernel length, kernet width, and consistency, but negatively correlating with pericarp thickness, hardness, gumminess, and chewiness.

• Korean Journal of Poultry Science
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• v.37 no.2
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• pp.117-123
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• 2010

This work was carried out to investigate the effect of the induced molting with low-protein and energy diet on the postmolt performance of layers. Eighty White Leghorn layers (61-old-wk) with over 80% egg production were used for 12 weeks in this work. Treatments were non-molt control (CO), fasting treatment for 10 days (FW), molt treatment with low-protein and low-energy molting diet for 3 weeks (LO), and molt treatment with standard molting diet for 3 weeks (ST) as 4 treatments (2 replications/treatment and 10 birds/replication). Body weight (BW) loss was 26.5% of initial BW at 2 week in FW treatment, and was 17.3% and 14.2% in both LO and ST treatments (P<0.05). Layers in molting treatments were fed with commercial layer diet after completion of molting since BW of layers was recovered for 7 weeks. Heart weight ratio was shown as 0.47, 0.43, 0.46 and 0.46% at CO, FW, LO and ST treatments, respectively, and liver weight ration of body weight was shown as 2.56, 1.30, 1.47 and 1.52%, respectively. Thus, those of molting treatments decreased compared to non-molt control (P<0.05). Oviduct weight ratio were shown as 3.95, 1.17, 1.54 and 1.67%, respectively, and similar with the results of liver (P<0.05). Feed intake decreased at LO and ST treatments during molting period and increased from the 5th week compared to control. Egg production decreased at 1 week in molt treatment and stopped at 2 week in FW, 3 week in LO, and 4 week in ST treatments. The birds started to lay egg at 4 week in FW and at 5 week in LO and ST treatments. Egg production was recovered until 50% at 6 week in FW and was recovered as 66.1 and 71.6% at 8 week in LO and ST treatment, respectively. Egg weights were similar among all treatments. Eggshell thicknesses were 0.41, 0.47, 0.46 and 0.46 mm at CO, FW, LO and ST treatment, respectively, but the higher in molt treatments than control (P<0.05). Eggshell breaking strength was 3.83 and 3.81 kg/$cm^2$ in FW and LO treatment, respectively, and high compared to control. However, eggshell breaking strengths were 3.54 and 3.78 kg/$cm^2$ and were not statistically different. Haugh units were 75.6, 81.1, 80.6 and 79.9 in 4 treatments and high in molt treatment. Finally, dietary low-protein and low-energy may induce molt as few effect on performance of layers.

• Journal of Chest Surgery
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• v.33 no.7
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• pp.531-540
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• 2000

Baclgrpimd; Recent studies have suggested that the cardioprotective effect of ischemic preconditioning(IP) is closely related to glycogen depletion and attenuation of intracellular acidosis. In the present study, the authors tested this hypothesis by perfusion isolated rabbit hearts with glucose(G) is closely related to glycogen depletion and attenuation of intracellular acidosis. In the present study, the authors tested this hypothesis by perfusion isolated rabbit hearts with glucose(G)-free perfusate. Material and Method; Hearts isolated from New Zealand white rabbits(1.5~2.0 kg body weight) were perfused with Tyrode solution by Langendorff technique. After stabilization of baseline hemodynamics, the hearts were subjected to 45 min global ischemia followed by 120 min reperfusion with IP(IP group, n=13) or without IP(ischemic control group, n=10). IP was induced by single episode of 5 min global ischemia and 10 min reperfusion. In the G-free preconditioned group(n=12), G depletion was induced by perfusionwith G-free Tyrode solution for 5 min and then perfused with G-containing Tyrode solution for 10 min; and 45 min ischemia and 120 min reperfusion. Left ventricular functionincluding developed pressure(LVDP), dP/dt, heart rate, left ventricular end-distolic pressure(LVEDP) and coronary flow (CF) were measured. Myocardial cytosolic and membrane PKC activities were measured by 32P-${\gamma}$-ATP incorporation into PKC-specific peptide and PKC isozymes were analyzed by Western blot with monoclonal antibodies. Infarct size was determined by staining with TTC(tetrazolium salt) and planimetry. Data were analyzed by one-way analysis of variance (ANOVA) and Turkey's post-hoc test. Result ; In comparison with the ischemic control group, IP significantly enhanced functional recovery of the left ventricle; in contrast, functional significantly enhanced functional recovery of the left ventricle; in contrast, functional recovery were not significantly different between the G-free preconditioned and the ischemic control groups. However, the infarct size was significantly reduced by IP or G-free preconditioning(39$\pm$2.7% in the ischemic control, 19$\pm$1.2% in the IP, and 15$\pm$3.9% in the G-free preconditioned, p<0.05). Membrane PKC activities were increased significantly after IP (119%), IP and 45 min ischemia(145%), G-free [recpmdotopmomg (150%), and G-free preconditioning and 45 min ischemia(127%); expression of membrane PKC isozymes, $\alpha$ and $\varepsilon$, tended to be increased after IP or G-free preconditioning. Conclusion; These results suggest that in isolated Langendorff-perfused rabbit heart model, G-free preconditioning (induced by single episode of 5 min G depletion and 10 min repletion) colud not improve post-ischemic contractile dysfunction(after 45-minute global ischemia); however, it has an infarct size-limiting effect.

• Journal of Preventive Medicine and Public Health
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• v.29 no.1 s.52
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• pp.133-143
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• 1996

This study was conducted to assess the referral patterns to specialist from general practitioners in health center and perceived needs of referred patients for specialist care in health center. The study subjects were 249 patients who visited to health centers and were referred to other medical facilities. The data were obtained from questionnaire survey which was conducted in Kyongju-City Health Center, Seongju-Gun Health Center and Koryong-Gun Health Center in Kyongsangbuk-Do, from June 10 to October 17, 1995. The total referral rate was 2.7%. The proportion of patients who wished to be referred to medical specialists was 85.9%, and the proportion of patients referred by general practitioners in health centers was 14.1%. Among the patients who wished to be referred to medical specialists, 45.9% visited directly to health centers, 34.6% visited health centers via local clinics and 19.5% visited health centers to get referral permission only. The reasons for getting referral permission in health centers were easy geographical accessibility(34.6%), easy to get referral permission in health centers(27.1%), and very difficult to get referral permission in local clinics(16.4%). Among the diseases of referred patients, diseases of the musculoskeletal system and connective tissue were most prevalent on a whole, but diseases of nervous system and sensory organs were comparatively high among the patients who wished to be referred to medical specialists and infectious and parasitic diseases were comparatively high among the patients referred by general practitioners in health centers. The most favorable medical facility was general hospital including university hospital in both groups of patients who wished to be referred to medical specialist and the patient referred by general practitioners in health centers. Regarding the needs for specialist care in health center, 75.2% of patients who wished to be referred to medical specialists and 74.3% of patients referred by general practitioners in health center wanted the specialist care. The most frequently requested specialty is internal medicine(47.1%), and then orthopedics and general surgery. Based on above results, this study revealed that the majority of patients referred from health center wished to be referred to medical specialists at their own will, so, referral system at health center level should be changed. And if specialist care in health center be provided, the medical care by internist could be provided first, and then that of orthopedics and general surgery could be provided. These kinds of medical cares could be covered by local clinicians as a part-time job on a voluntary basis.