HTA in den Entscheidungsprozessen des IQWiG und G-BA

The development of the German HTA system and the corresponding HTA law began in 2000 and was concluded for the time being with the coming into force of the law on the modernisation of statutory health insurance on 1 January 2004. This law has established the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWiG) as "new institutions" of statutory health insurance, restructured the procedures for the assessment of health services and formulated more precise assessment criteria than hitherto provided. There are other institutions in the health care system concerned with HTA which are not dealt with here.

Die Rolle von HTA-Berichten im deutschen Gesundheitswesen

Like other health technologies, HTA should be judged on the quality and size of its effects. However, it is only in recent years that this aspect has received increased attention. A comprehensive theoretical analysis is still missing. In this article national and international studies on the influence of HTA reports are presented. On the basis of theoretical models, the thesis is developed that the potential of HTA reports is much more extensive and complex than has been generally assumed. In order to make use of this potential, a stepwise procedure is proposed, comprising the involvement of the groups concerned, the explicit inclusion of impact objectives in all HTA reports, and the subsequent evaluation of the effects produced. This procedure is illustrated by the example of one HTA topic.

Gesundheitsökonomie und HTA

For a comprehensive health technology assessment (HTA), health economic studies are analysed as well as medical studies. Significance and effects of HTA are rather different in European countries. In Germany HTA is conducted by two official agencies: DIMDI and IQWiG. While DIMDI requires health economic assessments, IQWiG is prohibited from considering economic aspects by law (pure assessment of benefits). For the health economic assessment in HTA reports mainly secondary scientific evidence is exploited, i.e. primarily cost effectiveness and cost utility analyses. The study perspective, the study alternatives and the modelling methods are of great importance for the evaluation and have to be justified in depth. The cost effectiveness ratio and the budget impact are the most important results of the health economic assessment, which is the basis for the appraisal by the health care authorities. For this decision medical, utilitarian or other aspects like the avoidance of unwanted distribution effects are considered. On the other hand often only a few studies are available for the decision making when the appraisal has to be done. This problem might be less relevant in the near future as the number of HTAs and the number of health economic evaluations increases.

Toward a sustainable European Network for Health Technology Assessment

EUnetHTA is a recently initiated EU network aiming at connecting national HTA agencies, research institutions, and health ministries to enable an effective exchange of information and to lend support to health policy decisions by the Member States. The article briefly discusses the policy background, the specific objectives, and the project structure of the network.

Das Deutsche Netzwerk Evidenzbasierte Medizin — DNEbM

The German Network for Evidence-based Medicine (DNEbM) was founded in October 2000. A major impetus for the development of evidence-based medicine (EBM) in Germany came in the mid-1990s from the German Cochrane Initiative, which referred to the principles and activities of the international Cochrane Collaboration. The Network's primary mission is to establish a competence and reference centre for all aspects of evidence-based medicine. Central to this mission is to encourage projects that are concerned with scientific and methodological problems, aspects of professional development and the question of how to translate EBM into clinical practice. With currently more than 600 individual members the DNEbM is the most important society concerned with EBM in the German-speaking region in Europe. Until now, the DNEbM has initiated the development of curricula for EBM and health technology assessment (HTA) for undergraduate and continuing medical education. In addition, position papers regarding hot topics such as prostate cancer screening with PSA or registration of randomised controlled trials were published. The Network's HTA section comprises experts from universities, institutes, health care administration and industry. Currently, the HTA section is developing an Internet-based course for users and doers of HTA reports in Germany.

Die Rolle randomisierter kontrollierter Studien bei der medizinischen Bewertung von Routineverfahren

If a demand exists for the evaluation of the favourable and adverse effects of a medical procedure, a comparison is required; this comparison should be fair. The only procedure that ensures a fair comparison is randomisation. Randomised controlled trials (RCTs) therefore represent the gold standard in the evaluation of medical procedures; the non-application of a randomisation process must be justified in detail in individual cases. Reasons presented for not conducting an RCT are mainly based on a misunderstanding of the term "randomisation". They may also be based on circumstances where the conduct of any simultaneous comparison is unsuitable (independent of the mode of allocation) or on situations where there is practically no hypothesis available for a comparison, or even for a study. These factors are taken into account by the current regulations valid in Germany on the approval of drugs and on the reimbursement eligibility of health care services by statutory health insurance.

Context awareness in health care: a review

BACKGROUND

Health care systems will integrate new computing paradigms in the coming years. Context-awareness computing is a research field which often refers to health care as an interesting and rich area of application.

AIM

Through a survey of the research literature, we intended to derive an objective view of the actual dynamism of context awareness in health care, and to identify strengths and weaknesses in this field.

METHODS

After discussing definitions of context, we proposed a simple framework to analyse and characterize the use of context through three main axes. We then focused on context-awareness computing and reported on the main teams working in this area. We described some of the context-awareness projects in health care. A deeper analysis of the hospital-based projects demonstrated the gap between recommendations expressed for modelling context awareness and the actual use in a prototype. Finally, we identified pitfalls encountered in this area of research.

RESULTS

A number of opportunities remain for this evolving field of research. We found relatively few groups with such a specific focus. As yet there is no consensus as to the most appropriate models or attributes to include in context awareness. We conclude that a greater understanding of which aspects of context are important in a health care setting is required; the inherent sociotechnical nature of context-aware applications in health care; and the need to draw on a number of disciplines to conduct this research.

A novel processing method for injection-molded polyether–urethane scaffolds. Part 2: Cellular interactions

A large-scale scaffold processing method with injection molding has been successfully developed. Water was used as a foaming agent for the new technique. NaCl was used as a porogen to achieve an open-cell structure. Organic solvents, which are common foaming agents for polyurethane, where not used. Toxic remains in the polymer were therefore prevented. Biocompatibility tested gave a mean optical density of 81% from WST-1 proliferation assay. In comparison to the previously study processing method, hot pressing (Haugen H, Ried V, Brunner M, Will J, Wintermantel E. J Mater Sci: Mater Med2004;15:343-346), the current scaffolds had an increase of 20% of the mean optical density. Cell seeding showed that human fibroblasts adhered to the surface and proliferated. The spread of the adhered fibroblasts was uniform on the surface. A quantitative MTT analysis proved that there was a significant (p < 0.01) increase in the OD level after 7 and 14 days of incubation. This cell layer thickened with increased incubation time from 7 to 14 days (p < 0.05) and had typical fibroblast morphology.

Instrumentation system upgrade supports mobile personalized healthcare delivery

Clinicians and patients need mobile tools to detect ototoxic change early and prevent hearing loss. We report on the development of an upgrade of our existing desktop-based clinical-audiological instrumentation into a mobile instrument platform which efficiently supports personalized ototoxicity monitoring on the hospital wards as well as clinic by a trained clinician. Our new wireless-enabled system also serves as the instrumentation platform for the next phase of our work which is remote healthcare delivery with patient-guided at-home ototoxicity monitoring using an evidence-based individualized SRO protocol.

A novel processing method for injection-molded polyether–urethane scaffolds. Part 1: Processing

A large-scale scaffold processing method with injection molding has been successfully developed. Water was used as afoaming agent for the new technique. NaCl was used as a porogen to achieve an open-cell structure. Organic solvents, which are common foaming agents for polyurethane, where not used. Toxic remains in the polymer were therefore prevented. Pore size and porosity was adjustable through process parameters. A parameter study showed that an increase in injection pressure, plasticize speed, cylinder, and mold temperature raised the mean pore diameter. The porosity also could be mended by the cylinder and mold temperature, in addition to NaCl concentration. It was possible to produce scaffolds with a porosity of 64 +/- 3%, a pore size distribution from 30-450 microm, and a mean pore diameter of 270 +/- 90 microm. The interconnective pores were found to lie between 5 and 58 microm.

Trajectory of end-stage heart failure: the influence of technology and implications for policy change

Patients with end-stage heart failure have a trajectory of illness characterized by an overall gradual decline in function punctuated by periods of symptom exacerbation followed by a return nearly to their baseline. These exacerbations are not predictable. Death may come suddenly and unexpectedly for each patient, even though predictive models can draw an accurate survival curve by averaging the experience of a substantial number of people with heart failure. Heart failure patients often have treatable symptoms, such as dyspnea, fatigue, and generalized pain. In this article, we explain the trajectory of patients with heart failure, illustrate the importance of advance care planning for these patients, discuss the impact of choices to use or forgo new technologies, and suggest ways to improve the care system. Only by reexamining our health care spending priorities can we create a sustainable care system that allows patients to live both long and comfortably, reaching a balance that serves them and their communities well.

Is biomedical nuclear magnetic resonance limited by a revisitable paradigm in physics?

The history of nuclear magnetic resonance (NMR) can be divided generally into two phases: before the Second World War, molecular beam methods made it possible to detect the whole set of spins. However, these methods were destructive for the sample and had a very low precision. The publications of F. Bloch and E. Purcell in 1946 opened up a second phase for NMR with the study of condensed matter, but at the expense of an enormous loss in theoretical sensitivity. During more than half a century, the method of Bloch and Purcell, based on inductive detection of the NMR signal, has allowed many developments in biomedicine. But, curiously, this severely constraining limitation on sensitivity has not been called into question during this half-century, as if the pioneers of the pre-war period had been forgotten.

From concepts to clinical reality: an essay on the benchmarking of biomedical terminologies

It is only by fixing on agreed meanings of terms in biomedical terminologies that we will be in a position to achieve that accumulation and integration of knowledge that is indispensable to progress at the frontiers of biomedicine. Standardly, the goal of fixing meanings is seen as being realized through the alignment of terms on what are called 'concepts.' Part I addresses three versions of the concept-based approach--by Cimino, by Wüster, and by Campbell and associates--and surveys some of the problems to which they give rise, all of which have to do with a failure to anchor the terms in terminologies to corresponding referents in reality. Part II outlines a new, realist solution to this anchorage problem, which sees terminology construction as being motivated by the goal of alignment not on concepts but on the universals (kinds, types) in reality and thereby also on the corresponding instances (individuals, tokens). We outline the realist approach and show how on its basis we can provide a benchmark of correctness for terminologies which will at the same time allow a new type of integration of terminologies and electronic health records. We conclude by outlining ways in which the framework thus defined might be exploited for purposes of diagnostic decision-support.

Desiderata for domain reference ontologies in biomedicine

Domain reference ontologies represent knowledge about a particular part of the world in a way that is independent from specific objectives, through a theory of the domain. An example of reference ontology in biomedical informatics is the Foundational Model of Anatomy (FMA), an ontology of anatomy that covers the entire range of macroscopic, microscopic, and subcellular anatomy. The purpose of this paper is to explore how two domain reference ontologies--the FMA and the Chemical Entities of Biological Interest (ChEBI) ontology, can be used (i) to align existing terminologies, (ii) to infer new knowledge in ontologies of more complex entities, and (iii) to manage and help reasoning about individual data. We analyze those kinds of usages of these two domain reference ontologies and suggest desiderata for reference ontologies in biomedicine. While a number of groups and communities have investigated general requirements for ontology design and desiderata for controlled medical vocabularies, we are focusing on application purposes. We suggest five desirable characteristics for reference ontologies: good lexical coverage, good coverage in terms of relations, compatibility with standards, modularity, and ability to represent variation in reality.

Fourier transform infrared vibrational spectroscopic imaging: integrating microscopy and molecular recognition

The recent development of Fourier transform infrared (FTIR) spectroscopic imaging has enhanced our capability to examine, on a microscopic scale, the spatial distribution of vibrational spectroscopic signatures of materials spanning the physical and biomedical disciplines. Recent activity in this emerging area has concentrated on instrumentation development, theoretical analyses to provide guidelines for imaging practice, novel data processing algorithms, and the introduction of the technique to new fields. To illustrate the impact and promise of this spectroscopic imaging methodology, we present fundamental principles of the technique in the context of FTIR spectroscopy and review new applications in various venues ranging from the physical chemistry of macromolecular systems to the detection of human disease.

Applying health technology assessment to pharmaceutical care: pitfalls and future directions

It has been argued in previous issues of this journal that health technology assessment can be used as a tool to assess the eciency of pharmaceutical care by linking its impact on clinical and humanistic outcomes to the resources required to achieve these outcomes. Additionally, as policy-makers appreciate the need to evaluate projects on the basis of their costs and benefits, the application of health technology assessment to pharmaceutical care may serve as a way of communicating with policy-makers and informing policy on pharmaceutical care. This article elaborates on this idea by arguing that policy-makers will be more likely to appreciate the value of pharmaceutical care if researchers pay more attention to some methodological principles underlying health technology assessment in the context of pharmaceutical care, and if they take into account the decision-making context facing policy-makers. In order to raise the methodological quality of studies, researchers need to take care to define better the pharmaceutical care intervention; to evaluate the costs of the intervention and its impact on the utilization of other health services; and to aggregate the various clinical and humanistic outcome measures that are commonly used in this type of research. In order to increase the usefulness of study findings to policy-makers, researchers need to identify the multiple objectives that policy-makers pursue, and show how study findings will aid policy-makers in attaining these objectives.

Fractional calculus in bioengineering, part 3

Fractional calculus (integral and differential operations of noninteger order) is not often used to model biological systems. Although the basic mathematical ideas were developed long ago by the mathematicians Leibniz (1695), Liouville (1834), Riemann (1892), and others and brought to the attention of the engineering world by Oliver Heaviside in the 1890s, it was not until 1974 that the first book on the topic was published by Oldham and Spanier. Recent monographs and symposia proceedings have highlighted the application of fractional calculus in physics, continuum mechanics, signal processing, and electromagnetics, but with few examples of applications in bioengineering. This is surprising because the methods of fractional calculus, when defined as a Laplace or Fourier convolution product, are suitable for solving many problems in biomedical research. For example, early studies by Cole (1933) and Hodgkin (1946) of the electrical properties of nerve cell membranes and the propagation of electrical signals are well characterized by differential equations of fractional order. The solution involves a generalization of the exponential function to the Mittag-Leffler function, which provides a better fit to the observed cell membrane data. A parallel application of fractional derivatives to viscoelastic materials establishes, in a natural way, hereditary integrals and the power law (Nutting/Scott Blair) stress-strain relationship for modeling biomaterials. In this review, I will introduce the idea of fractional operations by following the original approach of Heaviside, demonstrate the basic operations of fractional calculus on well-behaved functions (step, ramp, pulse, sinusoid) of engineering interest, and give specific examples from electrochemistry, physics, bioengineering, and biophysics. The fractional derivative accurately describes natural phenomena that occur in such common engineering problems as heat transfer, electrode/electrolyte behavior, and sub-threshold nerve propagation. By expanding the range of mathematical operations to include fractional calculus, we can develop new and potentially useful functional relationships for modeling complex biological systems in a direct and rigorous manner. In Part 2 of this review (Crit Rev Biomed Eng 2004; 32(1):105-193), fractional calculus was applied to problems in nerve stimulation, dielectric relaxation, and viscoelastic materials by extending the governing differential equations to include fractional order terms. In this third and final installment, we consider distributed systems that represent shear stress in fluids, heat transfer in uniform one-dimensional media, and subthreshold nerve depolarization. Classic electrochemical analysis and impedance spectroscopy are also reviewed from the perspective of fractional calculus, and selected examples from recent studies in neuroscience, bioelectricity, and tissue biomechanics are analyzed to illustrate the vitality of the field.

Artifacts and collaborative work in healthcare: methodological, theoretical, and technological implications of the tangible

Although modeled as knowledge work with emphasis on data flow and decision making, healthcare is delivered in the context of a highly structured physical environment, with much effort and emphasis placed on physical and spatial arrangement and re-arrangement of workers, patients, and materials. The tangible aspects of highly collaborative healthcare work have profound implications for research and development of information and communication technology (ICT) despite the tendency to model work as flow of abstract data items. This article reviews field studies in healthcare and other domains on the role of artifacts in collaborative work and draws implications in three areas: methodological, theoretical, and technological. In regard to methodologies, assessment of new ICT and development of user requirements should take into account how artifacts are used and exploited to facilitate collaborative work. In regard to theories, the framework of distributed cognition provides a starting point for modeling the contribution and exploitation of physical artifacts in supporting collaborative work. In regard to technology, design and deployment of new technology should support the functions provided by physical artifacts replaced or disrupted by new technology, and profitable ways for new technology to support collaborative work by embedding ICT into existing infrastructure of physical artifacts.

Demon Rum: High-Tech Solutions to an Age-Old Problem

This article summarizes the proceedings of a symposium at the 2004 Research Society on Alcoholism Meeting in Vancouver, British Columbia, Canada, organized and chaired by Scott T. Walters. The purpose of the symposium was to describe several brief motivational interventions offered via the Internet, including the evidence for web-based interventions, applications and contexts in which such approaches are being used, and directions for future research. Walters provided an overview and introduction to the topic and discussed the e-CHUG (www.e-chug.com) and e-TOKE (www.e-toke.com) feedback interventions for college alcohol and marijuana prevention, including the contexts in which they are being used and ways they are being integrated with other campus prevention efforts. Dr. Hester presented 12-month results from a controlled trial of the Drinker's Check-up (www.drinkerscheckup.com), an intervention for adult problem drinkers that is available both as a Windows and as an Internet application. Dr. Chiauzzi described the development and testing of My Student Body (www.mystudentbody.com), a tailored drinking prevention web site for college students. Finally, Dr. Miller addressed the use of online assessment and feedback to reduce drinking, including the history of web-based interventions and their likely future and the potential limitations of such approaches.

Development of a virtual reality system for the rehabilitation of the upper limb after stroke

Virtual reality (VR) provides a three-dimensional computer representation of a real world or imaginary space through which a person can navigate and interact with objects to carry out specific tasks. One novel application of VR technology is in rehabilitation following stroke, particularly of the upper limb. This paper describes the development of a VR system for use in this field. This system gives the user the ability to interact with objects by touching, grasping and moving their upper limb.

Pseudo-thermosetting chitosan hydrogels for biomedical application

To prepare transparent chitosan/beta-glycerophosphate (betaGP) pseudo-thermosetting hydrogels, the deacetylation degree (DD) of chitosan has been modified by reacetylation with acetic anhydride. Two methods (I and II) of reacetylation have been compared and have shown that the use of previously filtered chitosan, dilution of acetic anhydride and reduction of temperature in method II improves efficiency and reproducibility. Chitosans with DD ranging from 35.0 to 83.2% have been prepared according to method II under homogeneous and non-homogeneous reacetylation conditions and the turbidity of chitosan/betaGP hydrogels containing homogeneously or non-homogeneously reacetylated chitosan has been investigated. Turbidity is shown to be modulated by the DD of chitosan and by the homogeneity of the medium during reacetylation, which influences the distribution mode of the chitosan monomers. The preparation of transparent chitosan/betaGP hydrogels requires a homogeneously reacetylated chitosan with a DD between 35 and 50%.

Wireless technologies in health care

Advances in wireless technology are opening up an ever-increasing field of opportunities for cost reduction, increased patient safety, better data collection and increased convenience for practitioners and patients. This overview of developments highlights the technical solutions on offer for new medical devices.

Monitoring of symptoms and interventions associated with multiple sclerosis

We have utilized the Structured Data Entry approach to build a prototype interface for the recording of personalized symptoms associated with Multiple Sclerosis (MS). The software provides both graphical input and output, to facilitate efficient data entry and monitoring. Graphical input is transformed to textual information, which is stored in a database in a hierarchical tree structure. Pain management in MS may be achieved by careful monitoring of the symptom in response to treatment. Pain location is selected on a body image and severity and other attributes represented using a graphical visual analog scale, leading to more convenient input and a less ambiguous coding than is achievable with narrative text alone. The Internet can be used to record and provide access to clinical data, assisting the citizen by providing a healthcare professional partnership approach to care. This approach could provide an objective means of monitoring symptoms and hence provide a more personalized approach to MS management.

The emergence of radically new health care technologies: inventive users as innovation networkers

Besides a large body of research on user innovation, little is known which role users play in the emergence of radically new health care technologies. Such technologies are 'new-to-the-world', highly complex, shift market structures, and require user learning as they often induce significant behaviour changes on side of the users. In a multi-case-study-analysis we identified an 'entrepreneurial' role of inventive users. Those surgeons that were the original inventors of radically new health care technologies established and organized the required innovation networks. They identified relevant partners, formed a network of experts with complementary knowledge bases, and coordinated this network. These innovation networks were required to transform their radically new ideas into first physical prototypes. To better understand the observed phenomenon we analysed factors that might explain this exclusive role. We find that a high problem pressure, an active role of users in the idea generation phase, a high degree of innovativeness of the prospective product, and missing competencies as well as missing resources explain the networking activities of inventive users. The findings shed light on the role of users in the emergence of radically new health care technologies.

Engineering and medical applications of diatoms

Biologists, and diatomists in particular, have long studied the properties of single-cell algae, and engineers are just discovering how to exploit features unique to these organisms. Their uniform nanopore structure, microchannels, chemical inertness, and silica microcrystal structure suggest many nanoscale applications. This paper proposes three potential research initiatives taking advantage of diatom morphology and mechanical and chemical properties: (1) embedding diatom frustules in a metal-film membrane; (2) magnetizing frustules for pinpoint drug delivery; and (3) producing silica nanopowders from frustules. The potential benefits of each initiative and its technical challenges are outlined.

Homecare service perspective in Tuscany: vision and new user centred services

"With medical knowledge expanding every day, no physician can keep up without help. By using high-tech medical communication, high-performance computers, high resolution video, and fibre-optic information "superhighways," we have been able to put the entire world of medical science at the fingertips of even the most isolated rural family doctor." [1] This quote by a former Surgeon General encapsulates the promise and potential for healthcare technology. Service organization and stakeholders' commitment are the real crucial issues for actual e-Health services deployment. In such a contest Homecare services start playing such a role of services integration and new care models development.

The scanning laser ophthalmoscope--a review of its role in bioscience and medicine

The scanning laser ophthalmoscope (SLO) offers the potential for retinal imaging that is complementary both to that of the fundus camera and also the newly developing technique of optical coherence tomography (OCT). It has the ability to produce rapid images at low light levels using light of specific wavelengths. This permits temporal studies of fluorescent-labelled cells which offer a unique insight into inflammatory processes in the eye. The facility to image with several different wavelengths simultaneously offers the potential for spectral imaging of retinal tissue with the aim of revealing those early changes in tissue perfusion that indicate the onset of retinal disease, so increasing the probability of successful therapy.

Pseudo-thermosetting chitosan hydrogels for biomedical application

To prepare transparent chitosan/beta-glycerophosphate (betaGP) pseudo-thermosetting hydrogels, the deacetylation degree (DD) of chitosan has been modified by reacetylation with acetic anhydride. Two methods (I and II) of reacetylation have been compared and have shown that the use of previously filtered chitosan, dilution of acetic anhydride and reduction of temperature in method II improves efficiency and reproducibility. Chitosans with DD ranging from 35.0 to 83.2% have been prepared according to method II under homogeneous and non-homogeneous reacetylation conditions and the turbidity of chitosan/betaGP hydrogels containing homogeneously or non-homogeneously reacetylated chitosan has been investigated. Turbidity is shown to be modulated by the DD of chitosan and by the homogeneity of the medium during reacetylation, which influences the distribution mode of the chitosan monomers. The preparation of transparent chitosan/betaGP hydrogels requires a homogeneously reacetylated chitosan with a DD between 35 and 50%.

Supplementation of a home-based exercise programme with a class-based programme for people with osteoarthritis of the knees: a randomised controlled trial and health economic analysis

OBJECTIVES

To establish the relative effectiveness and cost of providing a home-based exercise programme versus home-based exercise supplemented with an 8-week class-based exercise programme.

DESIGN

The trial was a pragmatic, single-blind randomised clinical trial accompanied by a full economic evaluation.

SETTING

Patients were randomly allocated to either home-based exercise or home exercise supplemented with class exercise programmes.

PARTICIPANTS

A total of 214 patients, meeting the American College of Rheumatology's classification of knee osteoarthritis, were selected from referrals from the primary and secondary care settings.

INTERVENTIONS

Both groups were given a home exercise programme aimed at increasing lower limb strength, and endurance, and improving balance. The supplemented group also attended 8 weeks of twice-weekly knee classes run by a physiotherapist. Classes represented typical knee class provision in the UK.

MAIN OUTCOME MEASURES

Assessments of locomotor function, using a timed score of three locomotor activities, walking pain and self-reported disability with the Western Ontario and McMaster's Universities osteoarthritis index (WOMAC) were made. General health, lower limb strength, range of movement and compliance with exercise were also measured. Patients were assessed before and after treatment, and also at 6- and 12-month follow-ups. The economic evaluation looked at health service resource use and assessed cost-effectiveness by relating differential costs to differences in quality-adjusted life-years (QALYs) based on patients' responses to the EuroQol-5 Dimensions. Data were obtained at baseline, 1 month, 6 months and 12 months through face-to-face interviews and, where appropriate, examination of hospital medical records.

RESULTS

Patients from the supplemented group demonstrated significantly greater improvement in locomotor function and decrease in pain while walking at all follow-ups. The supplemented group also demonstrated smaller but significant improvements in balance, strength, WOMAC score, and the physical function and pain dimensions of the Short Form-36. However, not all of these improvements were maintained over the 12-month follow-up period. There was no evidence that compliance with the home exercise programme was different or that total costs or mean QALY gains were significantly different between the groups. However, costs were slightly lower and QALY gains slightly higher in the group with the supplementary class-based programme. The economic evaluation suggests that supplemented programmes are likely to be considered cost-effective, although there is uncertainty around this estimate, with approximately 30--35% probability that the intervention would not be cost-effective.

CONCLUSIONS

The supplementation of a home-based exercise programme with a class-based exercise programme led to superior improvement in the supplemented group. These differential improvements were still evident at review 12 months after treatment had ceased. The additional cost of the supplemented group was offset by reductions in resource use elsewhere in the system. Compliance with the home exercise programme did not differ between the groups. Based on this evidence, the supplementation of a home-based exercise programme with an 8-week class-based exercise programme can be confidently expected to produce small improvements in locomotor function and clinically important reductions in pain. It is recommended that future research investigates methods of increasing compliance with home exercise programmes and evaluates the impact of these interventions in the primary care setting, where most patients with knee osteoarthritis are managed.

Autofluorescence spectroscopy of cells and tissues as a tool for biomedical diagnosis

Several biomolecules involved both in the metabolic processes and in the histological organization of cells and tissues are characterized by fluorescence properties that can be exploited to obtain information on the morpho-functional conditions of the biological substrate, suitable for diagnostic applications. An overview of the endogenous fluorophores responsible for the autofluorescence is given concerning the photophysical properties and their dependence on the evolution of the biological condition of cells and tissues.

Robust Model-Based Vasculature Detection in Noisy Biomedical Images

This paper presents a set of algorithms for robust detection of vasculature in noisy retinal video images. Three methods are studied for effective handling of outliers. The first method is based on Huber's censored likelihood ratio test. The second is based on the use of a alpha-trimmed test statistic. The third is based on robust model selection algorithms. All of these algorithms rely on a mathematical model for the vasculature that accounts for the expected variations in intensity/texture profile, width, orientation, scale, and imaging noise. These unknown parameters are estimated implicitly within a robust detection and estimation framework. The proposed algorithms are also useful as nonlinear vessel enhancement filters. The proposed algorithms were evaluated over carefully constructed phantom images, where the ground truth is known a priori, as well as clinically recorded images for which the ground truth was manually compiled. A comparative evaluation of the proposed approaches is presented. Collectively, these methods outperformed prior approaches based on Chaudhuri et al. (1989) matched filtering, as well as the verification methods used by prior exploratory tracing algorithms, such as the work of Can et aL (1999). The Huber censored likelihood test yielded the best overall improvement, with a 145.7% improvement over the exploratory tracing algorithm, and a 43.7% improvement in detection rates over the matched filter.

Fatigue characteristics of bioactive glass-ceramic-coated Ti–29Nb–13Ta–4.6Zr for biomedical application

A new surface-coating method by which CaP invert glass is used to improve the bioactivity of titanium alloys has been developed recently. In this method, the powder of CaP invert glass (CaO-P2O5-TiO2-Na2O) is coated on the surface of titanium alloy samples and heated between 1073 and 1123 K. With this treatment, a calcium phosphate layer mainly containing beta-Ca3(PO4)2 phase can be coated easily on titanium alloy samples. In the present study, the effect of this coating process on the fatigue properties of Ti-29Nb-13Ta-4.6Zr, a new metastable beta alloy for biomedical applications, has been investigated. The fatigue endurance limit of the coated alloy was found to be about 15% higher than that of uncoated alloy, as a result of the formation of a hard (alpha + beta) layer and a small amount of the omega phase during the coating process. The coating exhibits excellent adhesion to the substrate during the tensile and fatigue tests. Subsequent ageing at 673 K for 259.2 ks greatly improves the fatigue resistance of the coated alloy due to isothermal omega phase precipitation, and does not have obvious detrimental effect on the coating properties.

Application of Knowledge Information Processing Methods to Biochemical Engineering, Biomedical and Bioinformatics Fields

In biochemical and biomedical engineering fields there are a variety of phenomena with many complex chemical reactions, in which many genes and proteins affect transcription or enzyme activity of others. It is difficult to analyze and estimate many of these phenomena using conventional mathematical models. Recently some knowledge information processing methods, such as the artificial neural network (ANN), fuzzy reasoning, fuzzy neural network (FNN), fuzzy adaptive resonance theory (fuzzy ART) and the genetics algorithm (GA), were developed in the computer science field and have been applied to analysis in a variety of research fields. In this chapter, these methods will be briefly reviewed. Next, the application of these methods in the biochemical field will be introduced, instancing two examples in actual industrial processes. In addition, the application in the biomedical and bioinformatics field as another attractive field will be reviewed. Two examples are our research such as the prediction of prognosis for cancer patients from DNA microarray data using FNN and gene clustering for DNA microarray data using fuzzy ART.

Functional magnetic particles for medical application

Magnetic particles for medical applications have been developed by many researchers. Since magnetic particles have unique magnetic features not present in other materials, they can be applied to special medical techniques. Separation, immunoassay, magnetic resonance imaging (MRI), drug delivery, and hyperthermia are enhanced by the use of magnetic particles. Magnetite cationic liposomes (MCLs), one of the groups of cationic magnetic particles, can be used as carriers to introduce DNA into cells since their positively charged surface associates with the negatively charged DNA. MCLs can also be used as heat mediators for cancer therapy. Magnetic particles conjugated with tumor-specific antibodies have enabled tumor-specific contrast enhancement in MRI. In addition, antibody-conjugated magnetic particles were shown to target renal cell carcinoma cells, and are applicable to the hyperthermic treatment of carcinomas. It was also found that the hyperthermic treatment using magnetic particles induced an antitumor immunity. Thus, the use of magnetic particles with their unique features will further improve medical techniques.

Single Molecule Techniques for Biomedicine and Pharmacology

The present review gives a short summary on techniques useful for single molecule research, describes experiments on in vitro single molecule detection and reactions of single molecules and finally reports on the behavior of single molecules and single virus particles in living cells. One experiment on single molecule enzyme kinetics of lactate dehydrogenase, an enzyme used in the diagnosis of heart attacks and one experiment on restriction analysis of individual DNa molecules are described in some detail. Where it is possible, the relevance to pharmacology and biomedicine is emphasized, often as a perspective or suggestion for experiments, since in this young field of science a not too large variety of experiments have indeed already been devoted directly to drug action.

The postmodern heart: war veterans' experiences of invasive cardiac technology

BACKGROUND

The consequences of war and medical discourse have historical connections to pacemaker technology. Understanding these consequences is important because war veterans, medicine and cardiac technology have a shared history that continues into the present. The incidence of Australian war veterans needing cardiac pacemakers has increased many-fold in recent years, due to advancing age. This need was recognized by the Australian Department of Veteran Affairs and a cardiac programme was established in the veteran hospital that was the setting for this study.

AIM

This paper reports on a study aimed at capturing the interest and sensitizing the practice of nurses involved in the care of war veterans and other health care consumers who have been diagnosed as requiring a cardiac pacemaker. The study sought to answer the question, 'How does the war veteran experience his body in relation to invasive cardiac technology?'.

METHOD

The research was guided by the principles of interpretive interactionism, and used unstructured interviews with eight male war veterans. The data were collected in 2000.

FINDINGS

Thematic and content analysis revealed five themes: emotional knowing; the medical encounter; belief in the myth of miracle; technological constraint; and the altered heart. The findings indicated that the human dimension was characterized by experiences of ambivalence, inner conflict, powerlessness and suffering.

CONCLUSION

Nursing is at the interface of science and patient care, and this study contributes to nursing knowledge by focusing on a previously unresearched topic, namely embodied interactions between war veterans and invasive cardiac pacemakers. Within a highly technical area such as cardiology, nurses can still work around the technology and keep patients as their primary focus, thus promoting quality care. A humanistic rather than a technological focus locates nurses between patients and cardiac technology. In this in-between location, nurses are not an extension of cardiac technology but a valuable source of information, education, and counselling.

A new biomedical sensor for measuring PCO2

Measuring PCO2 (partial pressure of carbon dioxide) in an organ can enable early detection of ischemia. However, there are few clinical applicable solutions for measuring PCO2. Based upon the requirement for clinical applications, a conductivity based PCO2 sensor is proposed. A conductivity based PCO2 sensor measures conductance in an aqueous solution separated from the measured object by a gas-permeable membrane. A bridge design with two cavities is favored for such a sensor. A planar and a cylindrical macro prototype based upon the bridge design were studied. The design criteria were based on the contribution from the electrode polarization, stray capacitances, contact area with the sample and design ability to miniaturize the sensor. The cylindrical sensor is favored because of its large contact area and advantages for miniaturization. Further investigation has to be done to confirm the functionality of such a design in a miniaturized form and its clinical performance.

I-wear for health care and wellness--state of the art and future possibilities

The background of the development of i-wear for health care and wellness are two actual trends: The wellness trend with its expectation to stay fit and healthy and the increasing life expectancy of the Europeans and the challenges, which are resulting thereof for the medicine and the technology that goes with it. Already in 2040 the amount of people over 60 years in Europe will amount to 40% of the entire population [1,2]. In recent years the co-operation of physicians, biologists, physiologists, engineers for electronics and information technologies and textile scientists has produced a multitude of innovative applications for textiles, especially in the medical and wellness field. This presentation will cover the state of the art and some future aspects of textile-integrated solutions for health and wellness services, with intelligent application forms or integrated electronics (i-wear), which are an increasing market for textiles.