Challenges and perspectives of computer-assisted instruction in medical education: lessons learned from seven years of experience with the CAMPUS system

OBJECTIVES

In this paper we discuss solutions to the problem that medical teachers and students do not use modern computer-assisted instruction systems in medical education as much as expected by their developers.

METHODS

As an example for a modern problem-based CAI system we introduce the CAMPUS shell system for case-based training in medicine.

RESULTS

CAMPUS has received several awards and positive evaluation results. Nevertheless, the usage of such systems in courses and for self-study could be increased.

CONCLUSIONS

Curricular integration of CAI as well as further improvements on existing CAI systems to increase the usage in medical education is essential.

[Autoimmune pancreatitis--a surgical disease?]

The term autoimmune pancreatitis (AIP) describes a nonalcoholic, chronic lymphoplasmocytic pancreatitis. The lymphoplasmocytic infiltration is characterized by periductal localization of predominantly CD4-positive T cells, fibrosis, and acinar atrophy, frequently resulting in stenosis of the main pancreatic and distal common bile ducts. Imaging studies often reveal a diffuse narrowing of the pancreatic main duct and swelling of the pancreatic head wrongly suggesting the presence of a malignant tumor. Clinical signs include mild abdominal pain, jaundice, recurrent episodes of acute pancreatitis, and even new-onset diabetes mellitus. Additionally, AIP can be associated with other autoimmune diseases such as Sjögren's syndrome, primary sclerosing cholangitis, chronic inflammatory bowel diseases, and retroperitoneal fibrosis. Serological markers include autoantibodies and increased levels of gamma globulin and especially IgG4. Steroids seem to be effective in improving clinical symptoms as well as in the resolution of pancreatic and bile duct narrowing. This distinguishes AIP from other forms of pancreatitis and from pancreatic neoplasms. Further studies of the underlying pathophysiologic mechanisms, prognosis, and new diagnostic tools are needed to provide adequate and effective treatment in the future. In this article, we summarize the current knowledge about AIP and present 17 cases that underwent surgical resection at our institution from 2003 to 2004.

Towards clinical bioinformatics: advancing genomic medicine with informatics methods and tools

OBJECTIVES

To summarize the challenges facing clinical applications in the light of growing research results in genomic medicine and bioinformatics.

METHODS

Analysis of the contents of the Yearbook of Medical Informatics 2004 of the International Medical Informatics Association (IMIA).

RESULTS

The Yearbook of Medical Informatics 2004 includes 32 articles selected from 22 peer-reviewed scientific journals. A special section on clinical bioinformatics highlights recent developments in this field. Several guest editors review the promises and limitations of available methods and resources from biomedical informatics that are relevant to clinical medicine. Integrated data and knowledge resources are generally regarded to be central and key issues for clinical bioinformatics. Further review papers deal with public health implications of bioinformatics, knowledge management and trends in health care education. The Yearbook includes for the first time a section on the history of medical informatics, where the significant impact of the Reisensburg protocol 1973 on international health and medical informatics education is examined.

CONCLUSIONS

Close collaboration between bioinformatics and medical informatics researchers can contribute to new insights in genomic medicine and contribute towards the more efficient and effective use of genomic data to advance clinical care.

Medical informatics and the quality of health: new approaches to support patient care - findings from the IMIA Yearbook of Medical Informatics 2003

OBJECTIVES

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of excellent papers on medical informatics research which have been recently published (http://www. yearbook.uni-hd.de). The 2003 Yearbook of Medical Informatics took as its theme the role of medical informatics for the quality of health care. In this paper, we will discuss challenges for health care, and the lessons learned from editing IMIA Yearbook 2003.

RESULTS AND CONCLUSIONS

Modern information processing methodology and information and communication technology have strongly influenced our societies and health care. As a consequence of this, medical informatics as a discipline has taken a leading role in the further development of health care. This involves developing information systems that enhance opportunities for global access to health services and medical knowledge. Informatics methodology and technology will facilitate high quality of care in aging societies, and will decrease the possibilities of health care errors. It will also enable the dissemination of the latest medical and health information on the web to consumers and health care providers alike. The selected papers of the IMIA Yearbook 2003 present clear examples and future challenges, and they highlight how various sub-disciplines of medical informatics can contribute to this.

[Hereditary amyloidoses associated with transthyretin mutations]

Hereditary amyloidoses form a clinically and genetically heterogeneous group of autosomal-dominantly inherited diseases characterized by the ubiquitous extracellular deposit of fibrillary aggregated proteins. Main components of these unsolvable deposits are physiologic proteins that became amyloidogenic through genetically determined conformation changes resulting in an increase in beta-sheet structures. In the vast majority of cases, the offending protein is variant transthyretin (TTR), of which over 80 mutations are known. Among these, substitution of valine by methionine in position 30 (TTR-Met30) is the most commonly encountered. In typical cases, TTR amyloidoses present with polyneuropathy, carpal tunnel syndrome, autonomic insufficiency, cardiomyopathy, and gastrointestinal features, occasionally accompanied by vitreous opacities and renal insufficiency. Rarely, involvement of the leptomeningeal or meningovascular structures dominates the clinical picture. The clinical expression is highly variable, with many atypical manifestations. Asymptomatic mutations have recently been identified. The age of onset varies greatly between early adulthood and old age. Late-onset atypical manifestations and occurrence of asymptomatic carriers render identification of affected family members difficult despite autosomal-dominant inheritance. Orthotopic liver transplantation (OLT) is the only effective therapy available today. This OLT stops progression of the disease, which is otherwise invariably fatal, by removal of the main production site of the amyloidogenic protein. However, cardiac involvement may progress after OLT for unknown reasons. The indication for OLT and its success depend on the grade of cardiovascular and autonomic dysfunction at the time of surgery, age, comorbidity, and type of mutation. Alternative treatment modalities with drugs stabilizing the native tetrameric conformation of TTR, inhibiting fibril formation or breaking beta-sheet structures, are currently being intensively studied.

Medical Imaging Informatics and Medical Informatics: opportunities and constraints. Findings from the IMIA yearbook of Medical Informatics 2002

OBJECTIVES

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.yearbook.uni-hd.de). The 2002 Yearbook of Medical Informatics took as its theme the topic of Medical Imaging Informatics. In this paper, we will summarize the contributions of medical informatics researchers to the development of medical imaging informatics, discuss challenges and opportunities of imaging informatics, and present the lessons learned from the IMIA Yearbook 2002.

RESULTS AND CONCLUSIONS

Medical informatics researchers have contributed to the development of medical imaging methods and systems since the inception of this field approximately 40 years ago. The Yearbook presents selected papers and reviews on this important topic. In addition, as usual, the Yearbook 2002 also contains a variety of papers and reviews on other subjects relevant to medical informatics, such as Bioinformatics, Computer-supported education, Health and clinical management, Health information systems, Knowledge processing and decision support, Patient records, and Signal processing.

Review of the effect of the dosing interval for inhaled corticosteroids in asthma control

BACKGROUND

Asthma is recognized as an inflammatory disease of the airways and treatment includes anti-inflammatory agents such as corticosteroids. Inhaled corticosteroids (ICS) are widely prescribed for long-term prophylaxis, yet their optimal dosing interval is not clear.

AIMS

To determine whether the dosing interval of ICS affects asthma control.

METHODS

We performed an electronic search of the literature to identify studies on the dosing interval of ICS in asthmatic subjects. Data were extracted from suitable studies by two independent researchers and, where possible, a meta-analysis performed.

RESULTS

A total of 4,267 titles were retrieved, of which 13 met inclusion and exclusion criteria and 11 had extractable data. There were no significant differences between outcomes for: (i) once daily vs twice daily administration (7 trials, 810 subjects), (ii) once daily vs four times daily administration (2 trials, 68 subjects) and (iii) twice daily vs four times daily administration (4 studies, 111 subjects). There was a variety of outcomes used to assess differences between dosing intervals. These included symptom scores, lung function, use of rescue medication and adverse drug effects. The number of subjects that could be included in the statistical analysis of any of such outcomes was small, much smaller than the total sample size.

CONCLUSIONS

There was no significant difference in measures of asthma control between the assessed dosing intervals of ICS. Current evidence indicates that single daily administration of ICS produces equivalent asthma control to multiple daily administration.

Blood gases and oximetry: calibration-free new dry-chemistry and optical technology for near-patient testing

The first calibration-free Near-Patient-Testing instrument (NPT7) for blood gases, pH and oximetry has been developed. With cartridges of 30 single-use cuvettes, the NPT7 needs no preparation prior to sample aspiration, no manual calibration, and no maintenance apart from paper and cartridge changes and regulatory quality control. Each cuvette measures pCO2, pO2, pH, total hemoglobin (ctHb), oxygen saturation (sO2), fractions of carboxyhemoglobin (FCOHb) and methemoglobin (FMetHb) on 95 microl whole blood with a 110-s measuring cycle. The measurement principles are as follows: pCO2-three-wavelength infrared spectroscopy of dissolved CO2; pO2-measurement of O2-induced changes in the decay time of phosphorescence; pH-the absorbance spectra change of an azo-dye color indicator; and oximetry is performed with a 128-wavelength spectrophotometer. We determined the within and between instrument variations with tonometered whole blood on seven prototype instruments, using between one and five control levels per analyte. The 95% analytical performance limits: +/-(/Bias/ +2 xS(T)) in the NPT7 instrument matched the analytical performance criteria for the measured quantities as defined by AACC guidelines. The application of these optical measuring methods for blood gases, pH and oximetry in single-use devices introduces a new concept into point-of-care testing (POCT), where preanalytical activities otherwise associated with instrument preparation are eliminated.

Digital Libraries and Recent Medical Informatics Research. Findings from the IMIA Yearbook of Medical Informatics 2001

The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.med.uni-heidelberg.de/mi/yearbook/index.htm). The special topic of the just published Yearbook 2001 is "Digital Libraries and Medicine". Digital libraries have changed dramatically and will continue to change the way we work with medical knowledge. The selected papers present recent research and new results on digital libraries. As usual, the Yearbook 2001 also contains a variety of papers on other subjects relevant to medical informatics, such as Electronic Patient Records, Health Information Systems, Health and Clinical Management, Decision Support Systems, Education, as well as Image and Signal Processing. This paper will briefly introduce the contributions covering digital libraries and will show how medical informatics research contributes to this important topic.

Sequential (domino) transplantation of the liver in a transthyretin-50 familial amyloid polyneuropathy. Special reference to cardiological diagnosis and complications

BACKGROUND

General shortage of cadaveric organs has led to a search for alternative methods to expand the donor pool. Sequential (domino) transplantation is yet another attempt to compensate for the declining consent to organ donation.

PATIENTS AND METHODS

To qualify for a domino liver transplantation, the following preconditions must be fulfilled: (1) extrahepatic disease must exist, (2) liver must be fully functional, and (3) the genetic defect in the host should recur within a sufficient latency period. Familial amyloid polyneuropathy (FAP) is an autosomal dominant disease which involves a genetic defect for transthyretin (TTR), which is predominantly produced in the liver.

RESULTS

In this report, we describe a rare case of a FAP TTR-50 variant undergoing domino liver transplantation. Since myocardial symptoms precede peripheral polyneuropathy, special emphasis should be placed on arrhythmias and the restrictive cardiomyopathy necessitating a veno-venous bypass or a cardiac pacemaker in order to improve cardiac contractility. The type of anastomosis of the suprahepatic inferior vena cava and possible alternatives are discussed.

CONCLUSION

Despite ethical problems, the advantages of the domino procedure are obvious: (1) expansion of the donor pool, (2) ability to use living donors, and (3) presence of very short ischemic time and thus excellent liver function. Due to the kinetics of TTR production and deposition, donors and recipients of FAP livers should be followed up using an extensive neurological and cardiological protocol.

Introduction of new technology to the office

In this article, the authors review the basics of effective marketing and introduction of new technology for plastic surgery. The article addresses the financial issues involved in this new technology, as well as issues of staffing, safety and efficacy of the procedure, insurance, and use of the new equipment. The article closes with an affirmation of the importance of training courses and the necessity of serving patient interests.