Smart Medical Information Technology for Healthcare (SMITH)

INTRODUCTION

This article is part of the Focus Theme of Methods of Information in Medicine on the German Medical Informatics Initiative. "Smart Medical Information Technology for Healthcare (SMITH)" is one of four consortia funded by the German Medical Informatics Initiative (MI-I) to create an alliance of universities, university hospitals, research institutions and IT companies. SMITH's goals are to establish Data Integration Centers (DICs) at each SMITH partner hospital and to implement use cases which demonstrate the usefulness of the approach.

OBJECTIVES

To give insight into architectural design issues underlying SMITH data integration and to introduce the use cases to be implemented.

GOVERNANCE AND POLICIES

SMITH implements a federated approach as well for its governance structure as for its information system architecture. SMITH has designed a generic concept for its data integration centers. They share identical services and functionalities to take best advantage of the interoperability architectures and of the data use and access process planned. The DICs provide access to the local hospitals' Electronic Medical Records (EMR). This is based on data trustee and privacy management services. DIC staff will curate and amend EMR data in the Health Data Storage.

METHODOLOGY AND ARCHITECTURAL FRAMEWORK

To share medical and research data, SMITH's information system is based on communication and storage standards. We use the Reference Model of the Open Archival Information System and will consistently implement profiles of Integrating the Health Care Enterprise (IHE) and Health Level Seven (HL7) standards. Standard terminologies will be applied. The SMITH Market Place will be used for devising agreements on data access and distribution. 3LGM² for enterprise architecture modeling supports a consistent development process.The DIC reference architecture determines the services, applications and the standardsbased communication links needed for efficiently supporting the ingesting, data nourishing, trustee, privacy management and data transfer tasks of the SMITH DICs. The reference architecture is adopted at the local sites. Data sharing services and the market place enable interoperability.

USE CASES

The methodological use case "Phenotype Pipeline" (PheP) constructs algorithms for annotations and analyses of patient-related phenotypes according to classification rules or statistical models based on structured data. Unstructured textual data will be subject to natural language processing to permit integration into the phenotyping algorithms. The clinical use case "Algorithmic Surveillance of ICU Patients" (ASIC) focusses on patients in Intensive Care Units (ICU) with the acute respiratory distress syndrome (ARDS). A model-based decision-support system will give advice for mechanical ventilation. The clinical use case HELP develops a "hospital-wide electronic medical record-based computerized decision support system to improve outcomes of patients with blood-stream infections" (HELP). ASIC and HELP use the PheP. The clinical benefit of the use cases ASIC and HELP will be demonstrated in a change of care clinical trial based on a step wedge design.

DISCUSSION

SMITH's strength is the modular, reusable IT architecture based on interoperability standards, the integration of the hospitals' information management departments and the public-private partnership. The project aims at sustainability beyond the first 4-year funding period.

[Evaluation and performance-based budgeting of the Halle University Outpatient Clinics]

The Medical School of Halle has fundamentally restructured the university hospital's outpatient clinics. This required a detailed analysis of costs, income, and organization, as well as a prospective survey. In a representative month, more than 15,000 consultations were documented. Of all visits, 9% were part of clinical trials, and 19% part of the teaching and training of students and young doctors. 52% of all appointments were follow-up consultations. Operative and non-operative specialties as well as general and specialist consultations displayed considerable differences. Clinics with a high rate of follow-up consultations attended to fewer trial participants than others. In comparison to a district covered by statutory health insurance physicians the proportion of oncological diagnoses in the university hospital outpatient clinics was markedly higher. Costs for the different specialties' outpatient clinics varied significantly; a positive correlation was noted between the percentage of oncological diagnoses and secondary costs. The outpatient clinics' commitment to the outpatient care of cancer patients exceeds by far the scientific focus of the Medical School of Halle and contributes greatly to the provision of regional health care services. Within the scope of the project, the annual faculty allowances to the outpatient clinics were reduced by 25%. Since 2003, 60% of the remaining total allowances have been made available to the departments as an output-related grant. It was crucial to the acceptance of this budgeting that the expenses saved were dedicated to the support of young scientists, that the budgeting was comprehensible and that scientific achievements and in future also high quality teaching will continue to help regain some of the money "lost".

Present status and perspectives of cell-based therapies for liver diseases

In recent years the interest in liver cell therapy has been increasing continuously, since the demand for whole liver transplantations in human beings far outweighs the supply. From the clinical point of view, transplantation of hepatocytes or hepatocyte-like cells may represent an alternative to orthotopic liver transplants in acute liver failure, for the correction of genetic disorders resulting in metabolically deficient states, and for late stage liver disease such as cirrhosis. Although the concept of cell therapy for various diseases of the liver is widely accepted, the practical approach in humans often remains difficult. An international expert panel critically discussed the recent published data on clinical and experimental hepatocyte transplantation and the possible role of stem cells in liver tissue repair. This paper aims to summarise the present status of cell based therapies for liver diseases and to identify areas of future preclinical and clinical research.

Expression of Notch-1 and its ligand Jagged-1 in rat liver during liver regeneration

The Notch/Jagged signaling pathway is important for cellular differentiation and proliferation. Its dysfunction is associated with human pathologies in several tissues including liver. Point mutations in Jagged-1 gene are the cause for Alagille syndrome, associated with paucity of intrahepatic bile ducts. To determine the putative role of the trans-membrane receptor Notch and its ligand Jagged-1 in liver regeneration, we investigated the expression of Notch and Jagged-1 in rat liver following 2/3 partial hepatectomy. Immunohistochemical staining of normal rat liver showed that Notch was expressed in hepatocytes, bile duct cells and endothelial cells, whereas Jagged-1 was expressed in bile duct cells and hepatocytes. Both Notch-1 and Jagged-1 proteins were upregulated in hepatocytes after partial hepatectomy up to day 4. After partial hepatectomy, nuclear translocation of the intracellular cytoplasmic domain of Notch (NICD) increased and peaked within 15 minutes, indicating the activation of Notch. Expression of the Notch-dependent target gene (HES-1) expression increased within 30-60 minutes. Addition of recombinant Jagged-1 protein to primary cultures of hepatocytes stimulated hepatocyte DNA synthesis. Furthermore, injection of silencing RNA for Notch and Jagged-1 to livers 2 days before partial hepatectomy significantly suppressed proliferation of hepatocytes at days 2 to 4 of the regenerative response. In conclusion, Notch/Jagged signaling pathway is activated during liver regeneration and is potentially contributing to signals affecting cell growth and differentiation.

Determinants of hyperhomocysteinemia in patients with chronic liver disease and after orthotopic liver transplantation

BACKGROUND

Homocysteine metabolism may be impaired in chronic liver disease, possibly contributing to fibrogenesis and disease complications.

OBJECTIVE

The goal was to investigate the prevalence and determinants of basal and postprandial hyperhomocysteinemia in patients with chronic liver disease and after orthotopic liver transplantation (OLT).

DESIGN

This was a cross-sectional study of 323 patients with chronic liver disease (93 with hepatitis, 8 with fatty liver, 168 with cirrhosis, and 54 after OLT) and 25 healthy control subjects. Portohepatovenous gradients of total homocysteine (tHcy) and methionine and postload methionine and tHcy kinetics before and after 10 d of supplementation with folate plus vitamin B-6 were investigated in subgroups.

RESULTS

Basal hyperhomocysteinemia was observed in all patient groups (34% of patients with hepatitis, 50% with fatty liver, 54% with cirrhosis, and 52% after OLT). It was more frequently seen in patients with elevated plasma creatinine concentrations and at advanced stages of liver disease. Mean plasma folate was normal in patients with liver disease, but vitamin B-12 was elevated in cirrhosis and vitamin B-6 was low after OLT. There were significant negative associations between tHcy and folic acid or vitamin B-12 concentrations in control subjects and in patients with hepatitis and after OLT. No systematic association between portohepatovenous differences in tHcy and methionine concentrations was found. Cirrhosis was accompanied by impaired methionine clearance. After vitamin supplementation, the area under the tHcy curve improved in cirrhosis at nearly unchanged basal tHcy concentrations.

CONCLUSIONS

Basal hyperhomocysteinemia is seen in approximately 50% of patients with cirrhosis and after OLT. Basal tHcy concentrations do not change significantly after supplementation with folate and vitamin B-6, but postprandial Hcy metabolism improves.

[Therapy of Crohn disease according to the guidelines of the German Society for the treatment of digestive and metabolic diseases]

Crohn's disease is still an incurable affliction: While various pathogenic mechanisms have been elucidated in detail, the etiology remains undetected. Conservative medical management is the mainstay of treatment with corticosteroids and azathioprin as pivotal drugs. Aminosalicylates are of minor importance. Infliximab may be effective for individual patients as a third line of treatment after failure of classical immunosuppression or when a rapid response is mandatory in a corticosteroid-resistant situation. Its long-term efficacy and safety in the treatment of fistulae is unknown. Antibiotics and nutritional measures may be of help in certain clinical conditions. Satisfactory means of maintaining remission in inactive patients is not available to date. Psychotherapy may be useful in helping patients to cope but does not significantly affect the course of the disease. The guidelines presented here are based on a consensus developed by the Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten in 1996 (26), updated in December 2001 (to be published) on the basis of recent randomized trials and meta-analyses.