Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures.

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20. BACKGROUND: Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term. OBJECTIVE: This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs. METHODS: This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors. RESULTS: The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]). CONCLUSIONS: We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Evaluation of two Japanese regulatory actions using medical information databases: a 'Dear Doctor' letter to restrict oseltamivir use in teenagers, and label change caution against co-administration of omeprazole with clopidogrel.

WHAT IS KNOWN AND OBJECTIVE: The implementation of appropriate epidemiological methodology using medical information databases (MIDs) to evaluate the effects of regulatory actions has been highly anticipated. To assess scientific methods for active pharmacovigilance using MIDs, we conducted a quantitative assessment of the impact of two regulatory actions by the Japanese government: (i) restriction of use of oseltamivir in teenagers in March 2007 and (ii) caution against the co-administration of omeprazole (OPZ) with clopidogrel (CPG) in April 2010. METHODS: Data were obtained from four hub hospitals in Japan. We measured the seasonal proportion of patients prescribed oseltamivir to those prescribed neuraminidase inhibitors for the 2002/2003 to 2010/2011 seasons. The monthly proportion of patients co-administered OPZ and CPG (OPZ+CPG) to those prescribed CPG was measured from May 2009 to April 2011. We evaluated the changes observed with implementation of the regulatory actions. To estimate the impact of the actions, we conducted segmented regression analysis using interrupted time series data. The impact was assessed by two parameter estimates of the regression model: the change in level for short-term effects and change in trend for long-term effects. RESULTS AND DISCUSSION: The use of oseltamivir in the target 10-19 years age group showed a significant and large decline (63·16%) immediately after the intervention (P = 0·0008). No change was observed in OPZ+CPG, although there was a relative inhibitory trend for OPZ+CPG compared with co-administration of lansoprazole or rabeprazole with CPG as the control group. When restricted to new users of CPG, the stratified results were consistent with the overall results. WHAT IS NEW AND CONCLUSION: The current analysis demonstrates the effectiveness of two regulatory actions. The results of the current study indicate that MID research can contribute to assessing and improving pharmacovigilance activities.

Development of a broadband telemedical network based on internet protocol in the Asia-Pacific region.

OBJECTIVES: To promote the exchange of knowledge and standardization of medical procedures and medical systems in the Asia-Pacific region, we established a medical network with high-quality moving images over broadband Internet lines in February 2003. METHODS: Real-time teleconferences and live demonstrations with medical-quality videos, broadcast via the Digital Video Transport System, have been used to teach surgical techniques and other medical procedures across national borders. The Asia-Pacific Advanced Network (APAN) committee in August 2005 formally approved our proposal to establish a medical working group within APAN. The network was expanded by the launch of the Trans-Eurasia Information Network 2 in 2006. By the end of 2006, we had conducted 82 events, in 10 countries in the Asia-Pacific region. The multi-station event has increased every year. RESULTS: There have been no serious transmission problems or ethical conflicts so far. With these experiences and current achievements, we hope to extend this advanced network system to the entire Asia-Pacific. CONCLUSION: This system is a promising and very useful tool for the standardization of medical system and procedures across national borders. Drawing upon these experiences and current achievements, we hope to extend this advanced network system to the entire Asia-Pacific region.

Merits of duplicate LAN cabling in hospitals.

Our hospital wired three LAN cables separately to improve the data distribution range. One LAN is between the various sections of the hospital (hospital LAN), another is within each section (section LAN), and the other is connected to the Internet (open LAN). The section LAN was connected to the hospital LAN to enable data exchange. Data from the section LAN for common use is collected through the hospital LAN and stored in the central server The duplicate cabling and separate LANs increased the independence of each LAN and the system within each section. The section systems can be changed at anytime without the necessity of reconstructing the whole hospital information system. The data transfer speed of each cable increased. Hospital information processing systems often use a distributed-processing centralized management system. Because of advances in technology, each section can now take responsibility for developing their own system, making the responsibility of the information processing section responsible for hospital information systems more limited than previously. Herein, we show the merits of separate cable installation.

A simple computerized program for the calculation of the required sample size necessary to ensure statistical accuracy in medical experiments.

We developed a sample size estimation program (SSEP) with which medical researchers can easily estimate the appropriate sample size for a specific significance level and statistical power using their favorite WWW browsers. SSEP can estimate the sample sizes for six statistical methods by Monte-Carlo simulation: Student's t-test, Welch's t-test, Analysis of variance, Wilcoxon's rank sum test, Kruskal-Wallis test, and the Cochran-Armitage test for linear trends. The SSEP simulation programs were created using the SAS software macro language. Medical researchers can interactively use this program and determine reliable sample sizes when planning new prospective clinical studies and animal experiments.

Correlations of elevated levels of hexacosanoate in erythrocyte membranes with risk factors for atherosclerosis.

We analyzed erythrocyte membrane C26:0 from 504 volunteers by high-performance liquid chromatography. The associations between the elevated levels of erythrocyte membrane C26:0 (0.20 or greater than 0.20%) and sex, obesity (body mass index> or =26.4), smoking (> or =20 cigarettes per day), present illnesses and past diseases were examined with the chi(2) test. The correlations among age and the levels of erythrocyte membrane C26:0, plasma total cholesterol, triglycerides, LDL cholesterol and HDL cholesterol were analyzed using Spearman's correlation coefficient. Moreover, the frequencies of high levels of erythrocyte membrane C26:0 were examined in male and female subjects divided into seven age groups. The elevated levels of erythrocyte membrane C26:0 were significantly more frequent in male subjects than in females, and were closely associated with obesity, smoking, and atherosclerosis-related diseases of present illnesses. The levels of erythrocyte membrane C26:0 were highly correlated with age and the levels of plasma total cholesterol, triglycerides and LDL cholesterol, and inversely with those of HDL cholesterol. The frequency of high levels of erythrocyte membrane C26:0 in male subjects was greater than that in female subjects in all of the seven age groups. Elevated levels of erythrocyte membrane C26:0 may be closely related with atherosclerosis.

Two novel mutations in the adrenoleukodystrophy gene in two unrelated Japanese families and the long-term effect of bone marrow transplantation.

We identified two novel missense mutations in exon 1 of adrenoleukodystrophy (ALD) gene in two unrelated Japanese families. The first, G(874)C transition results in Arg(163)Pro substitution in the cytoplasmic domain of the ALD protein in adrenomyeloneuropathy family. The second, C(679)G results in Ser(98)Trp substitution in the first transmembrane loop in childhood onset cerebral ALD family. Both mutations cause the substitution of polar amino acid (arginine and serine) with non-polar amino acid (proline and tryptophan). Bone marrow transplantation (BMT) from his non-affected his younger sister was performed on a boy with childhood onset cerebral ALD who showed neurological deficit and brain MRI abnormalities. We evaluated the effect of BMT over a 6-year period in terms of neurological deficit, the level of very-long-chain fatty acids (VLCFA) in plasma and fibroblasts, and brain MRI. After BMT, patient's peripheral white blood cells were replaced by donor's XX ones carrying a normal ALD gene confirmed by in situ hybridization using satellite DNA of the centromere of X and Y chromosomes as probes and the level of VLCFA in lymphocytes was within normal limit. However, his neurological state progressively deteriorated. BMT was not beneficial to him.

Advantages of low output mobile communication systems in hospitals.

Mobile telephone systems using radio waves with very low power outputs rarely interfere with electronic medical equipment, which allows them to be safely installed in hospitals. The Personal Handy-phone System, PHS, which was developed and is widely used in Japan, is one such system. It has many useful functions including voice communication, string message transfer, e-mail, an answering system limited to selected persons or groups, paging, automatic call transfer, and handset positioning. In this paper we discuss the benefits of these functions confer to hospital communication systems.

A question and answer E-mail system for responding to query from the general public with which the system manager can identify delayed replies.

We constructed a question and answer system for direct delivery of E-mail queries from the general public to the proper hospital representative and with which the system administrator can monitor E-mail replies. The system consists of two sub-systems; one is an E-mail questionnaire sub-system that automatically delivers E-mail queries to the proper person and an E-mail reply monitor sub-system with which the system administrator can monitor the E-mail replies. The monitor system compares the origin address of the E-mail reply and the destination address on a questionnaire filled out at the time the query is made. In a test of the system, 56 queries were received in 31 days, with 37 replied to. The interval from receipt of an E-mail query to reply was calculated. Nineteen replies were submitted within 2 days.

A simple client-server system using a personal computer as the server.

Hospital information systems have recently grown into huge, complex systems. As a result, the cost of development and maintenance of application programs has increased and become a serious problem. We have constructed an order entry system using server-client architecture as part of a hospital intranet information system in which a personal computer is used as a server. Using a commercial database management system and software development tools, an easily maintained order entry system was developed within only three months by one programmer. Since slow response when the number of clients increased was possible, we measured turn-around times when one or ten clients accessed simultaneously. Turn-around times were 8 and 10 sec, respectively. Because we expect much better performance from personal computers in the near future, application systems using personal computers as Intranet servers will be cost and time effective and easy to develop and maintain.

An easily customized, random allocation system using the minimization method for multi-institutional clinical trials.

In a randomized clinical trial, random allocation of patients to treatment groups should be done to balance in the distribution of prognostic factors. Random allocation in a multi-institutional randomized clinical trial is conducted by a coordinating center, independent of the medical institution the attending doctor uses for his/her practice. This study provides a sophisticated system for doing an exact random allocation of patients to treatment groups. The minimization method proposed by Pocock was applied to this system to balance the distribution of prognostic factors between two treatment groups, even when the number of registered patients is relatively small (S.J. Pocock, Allocation of patients to treatment in clinical trial, Biometrics 35 (1979) 183-197). Furthermore, Zelen's method is used to balance the number of patients allocated to the two groups within each institution (M. Zelen, The randomization and stratification of patients to clinical trials, J. Chron. Dis. 27 (1974) 365-375.). This system was created by the 'PERL&RSQUO; language for writing common gateway interface (CGI) script, and can therefore, be easily extended to include data entry function by attending doctors as well as the random allocation function. This system is being used effectively in thirteen multi-institutional randomized clinical trials for stomach, colon-rectum and breast cancers in Japan.

A keyword search system for medical doctors to introduce their patients to specialists.

We developed an online keyword search system on a WWW server to help medical doctors to introduce their patients to specialists. The system stores special knowledge and advanced techniques of 287 medical specialists in Kyushu University Hospital. The data set was presented by the medical specialists themselves. Specialists can rewrite their data set using the browser anytime to keep their data set up to date. In addition, the specialists are reminded to keep their data set up to date by direct mail once a year. The system does not use any database management systems. We used only two text files and the "grep" command, one of the basic commands of the UNIX system. Then, it takes less than 1 sec to search one medical specialist's data set from 200 specialists' data sets. The system is useful not only inside the hospital but also for practitioners in the local area.

Hospital construction materials: poor shielding capacity with respect to signals transmitted by mobile telephones.

Electromagnetic interference (EMI) with electronic medical equipment by the handsets of mobile telephones is a well documented problem in hospitals. To gain information about how to build an EMI-free hospital and how to make rooms safe for mobile telephone handset use in the hospital building the authors measured the shielding capacities of a concrete wall, concrete blocks, a steel door, and steel-surfaced partition panels. The shielding capacities of these materials were 2-7 dB for the concrete wall, 6-8 dB for the concrete blocks, 19-27 dB for the steel door, and 20-37 dB for the steel-surfaced partition panels. These results indicate that care should be taken to shield electronic equipment from signals coming from neighboring rooms and from those under and above any patient room in which such equipment is in use. Electricity-conductive paint, electricity-conductive wallpaper, and electricity-conductive cloth are examples of inexpensive materials that can increase shielding capacity.

Remote connection to the Kyushu University Medical Center LAN using digital and analog telephone lines.

SOHO (Small Office/Home Office) has recently become popular, as it makes working at home possible. Computers or Local Area Networks(LAN) connected to the office network from home are necessary for the implementation of this concept. Kyushu University has begun a service connecting home computers to the campus LAN for researchers, staff and students of the Faculty of Medicine. We have two different telephone connection methods. One connects the campus LAN and the home computer LAN using routers through the Integrated Services Digital Network (ISDN). The other connects computers at home to the workstation in the university, using modems and the PPP (Point to Point Protocol) through a public telephone analog line. This paper outlines our university SOHO connection system and discusses the merits and demerits of using telephone line connections.

A simple WWW interface and quick response system-information query system for cross-sectional body dimensions.

We developed a query and analysis system for normal growth measurement of Japanese children on our WWW server using CGI. It has two subsystems. The first shows standard height and standard weight calculated by height. This subsystem can calculate the difference between measured height and the standard along with deviation and the ratio of measured weight to the standard weight. The second shows standard height, weight, head circumference, and chest circumference. This subsystem can calculate differences between the measurements and the standard as well as deviation. Because of the low amount of output required, very short turn-around time was required. This system also allows use of the same interface no matter which brand terminal is used and has wide reusability. This system will save doctors and nurses the difficulty of looking up a child's data, then having to make the calculation. We also compare the merits of CGI and Java.

A family with Machado-Joseph disease, previously diagnosed as dentatorubral-pallidoluysian atrophy.

We report a family with Machado-Joseph disease (MJD) that was previously diagnosed with dentatorubral-pallidoluysian atrophy (DRPLA), on the basis of the neuropathologic findings. Because the clinical and pathologic reevaluation strongly suggested a diagnosis of MJD, we conducted a genetic study in the family. Two patients, aged 38 and 40, revealed CAG repeat lengths of the MJD1 gene of 80, 28 and 75, 14, confirming a final diagnosis of MJD.

Reserved Sertoli cell function in the hypogonadic male patients with myotonic dystrophy.

To clarify the Sertoli cell and Leydig cell function in hypogonadic male patients with myotonic dystrophy (DM), serum concentrations of inhibin, total testosterone (TT), follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were measured by radioimmunoassay in 6 male DM patients (41 to 56 years old, 47.7 +/- 5.05 years old) and compared with those in normal adult men. In 116 healthy men aged from 24 to 92 years, serum inhibin and TT levels decreased and serum FSH and LH concentrations increased with advancing age. There was an inverse correlation between serum inhibin and FSH. These results support the concept of negative feedback regulation system of FSH secretion by inhibin. Male DM patients showed significantly lower serum TT and higher concentrations of FSH and LH, compared with the age-matched 39 normal adult men (49-59 years old, 48.2 +/- 6.14 years old). However, there was no significant difference in serum inhibin levels between the patients and normal counterparts. These results indicate that the Sertoli cell function is reserved in male DM patient, although the Leydig cell function is impaired. It is also suggested that in these patients a negative feedback control system between inhibin and FSH may be disordered to some extent.

Adrenoleukodystrophy: a correlation between saturated very long-chain fatty acids in mononuclear cells and phenotype.

Saturated very long-chain fatty acids in erythrocyte membranes, blood plasma, and mononuclear cells were studied in 4 patients with childhood-adolescent adrenoleukodystrophy and 4 patients with adult adrenoleukodystrophy and 19 normal control subjects by using high-performance liquid chromatography. Ratios of C26:0 to C22:0 in mononuclear cells, erythrocyte membranes, and blood plasma in patients with childhood-adolescent and adult adrenoleukodystrophy were significantly higher than in normal control subjects. Furthermore, ratios of C26:0 to C22:0 in mononuclear cells were significantly higher in patients with childhood-adolescent adrenoleukodystrophy than in patients with adult adrenoleukodystrophy, whereas there was no significant difference in the ratios in erythrocyte membranes and blood plasma between the two groups of patients with adrenoleukodystrophy. These results suggest that there is a correlation between phenotype and ratio of C26:0 to C22:0 within mononuclear cells in patients with adrenoleukodystrophy.