An international summer school on health informatics: a collaborative effort of the Amsterdam Medical Informatics Program and IPhiE--the International Partnership for Health Informatics Education.

PURPOSE: Today, the need for health informatics training for health care professionals is acknowledged and educational opportunities for these professionals are increasing. To contribute to these efforts, a new initiative was undertaken by the Medical Informatics Program of the University of Amsterdam-Academic Medical Center and IPHIE (IPhiE)-the International Partnership for Health Informatics Education. In the year 2004, a summer school on health informatics was organized for advanced medical students from all over the world. METHODS: We elaborate on the goals and the program for this summer school. In developing the course, we followed the international guidelines of the International Medical Informatics Association-IMIA. Students provided feedback for the course through both summative and formative evaluations. As a result of these evaluations, we outline the lessons we have learned and what consequences these results have had in revising the course. RESULTS: Overall the results of both the summative and formative evaluation of the summer school showed that we succeeded in the goals we set at the beginning of the course. Students highly appreciated the course content and indicated that the course fulfilled their educational needs. The decision support and image processing computer practicums however proved too high level. We therefore will redesign these practicums to competence requirements of medical doctors as defined by IMIA. All participants recommended the summer school event to other students. CONCLUSIONS: Our experiences demonstrated a true need for health informatics education among medical students and that even a 2 weeks course can fulfill health informatics educational needs of these future physicians. Further establishment of health informatics courses for other health professions is recommended.

The International Partnership for Health Informatics Education: lessons learned from six years of experience.

OBJECTIVES: To inform the medical and health informatics community on the rational, goals, and the achievements of the International Partnership for Health Informatics Education--IPHIE, (I phi E), that was established at six universities in 1999. METHODS: We elaborate on the overall goals of I phi E and describe the current state of affairs: the activities undertaken and faculty and student experience related to these activities. In addition we outline the lessons we have learned over these past six years and our plans for the future. RESULTS: I phi E members first started to collaborate by supporting and encouraging the exchange of talented students and faculty and by establishing joint master classes for honors students. Following the success of these activities, new initiatives were undertaken such as the organization of student workshops at medical informatics conferences and a joint course on strategic information management in hospitals in Europe. CONCLUSIONS: International partnerships such as I phi E take time to establish, and, if they are to be successful, maintaining leadership continuity is critically important. We are convinced that I phi E promotes professionalism of future medical informatics specialists. There will be a continuing growth of globalization in higher education. It will therefore become increasingly important to offer educational programs with international components.

The International Partnership in Health Informatics Education.

The International Partnership for Health Informatics Education (IPHIE) seeks to promote education through international collaboration of graduate and undergraduate training programs in Medical and Health Informatics. In 1998 an International Partnership of Health Informatics Education was established at six universities: The University of Amsterdam, the Universities of Heidelberg and Heilbronn, the University of Health Informatics and Technology Tyrol at Innsbruck, the University of Minnesota and the University of Utah. The overall goal of this cooperation was to form a network for training and educating medical informatics faculty and students in order to prepare them for leading international positions in medical information and communication technology. In this paper we describe the current state of affairs of IPhiE: the activities undertaken, our experiences, the lessons we have learned over these past five years. In addition we outline our plans for the future.

International Master Classes in health informatics.

Master Classes arose within the performing arts and are now being offered in system sciences. The IPhiE group of faculty from six universities in Europe and the United States has offered Master Classes in health informatics to provide an integrative forum for honors students. Featured are international views of health systems, varied opportunities for student interaction and promotion of informatics professionalism. Five years of experience indicate the success of this concept and suggest changes that will be considered for the future.

A national agenda for public health informatics.

The American Medical Informatics Association 2001 Spring Congress brought together the public health and informatics communities to develop a national agenda for public health informatics. Discussions on funding and governance; architecture and infrastructure; standards and vocabulary; research, evaluation, and best practices; privacy, confidentiality, and security; and training and workforce resulted in 74 recommendations with two key themes: (1) all stakeholders need to be engaged in coordinated activities related to public health information architecture, standards, confidentiality, best practices, and research and (2) informatics training is needed throughout the public health workforce. Implementation of this consensus agenda will help promote progress in the application of information technology to improve public health.

Setting-based practice variation in the management of simple febrile seizure.

OBJECTIVE: To identify provider-based differences in the ED assessment and management of children presenting with uncomplicated, first-time febrile seizures. METHODS: Multicenter, retrospective cohort study of seven EDs in-the Chicago area: two tertiary academic pediatric EDs (PEDs) and five community-based general EDs (GEDs). The visits of all patients with a discharge diagnosis including the term "seizure" were identified from a 30-month period. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure <20 minutes; "alert" or "arousable" on presentation; absence of known neurologic disease). RESULTS: Four hundred fifty-five records were included: 330 and 125 patients presenting to GEDs and PEDs, respectively. The two groups did not differ in mean age, vital signs, reported duration of seizure, or prior antibiotic use. Lumbar puncture (LP) was performed more often in the GED group (33% vs 22%). No patients were found to have bacterial meningitis. The patients in the GED group were more likely to receive parenteral antibiotics in the ED (56% vs 22%) and to be admitted or transferred (18% vs 4%). In a logistic regression model incorporating age, temperature, seizure duration, seizure in the ED, prior antibiotic use, primary care, and insurance status, the GED patients remained more likely to have an LP (OR 1.5), receive parenteral antibiotics (OR 2.5), and be admitted or transferred (OR 2.5). CONCLUSIONS: There were significant setting-based differences in the evaluation and management of children with simple febrile seizures presenting to GEDs and PEDs.

IPHIE: an International Partnership in Health Informatics Education.

Medical informatics contributes significantly to high quality and efficient health care and medical research. The need for well educated professionals in the field of medical informatics therefore is now worldwide recognized. Students of medicine, computer science/informatics are educated in the field of medical informatics and dedicated curricula on medical informatics have emerged. To advance and further develop the beneficial role of medical informatics in the medical field, an international orientation of health and medical informatics students seems an indispensable part of their training. An international orientation and education of medical informatics students may help to accelerate the dissemination of acquired knowledge and skills in the field and the promotion of medical informatics research results on a more global level. Some years ago, the departments of medical informatics of the university of Heidelberg/university of applied sciences Heilbronn and the university of Amsterdam decided to co-operate in the field of medical informatics. Now, this co-operation has grown out to an International Partnership of Health Informatics Education (IPHIE) of 5 universities, i.e. the university of Heidelberg, the university of Heilbronn, the university of Minnesota, the university of Utah and the university of Amsterdam. This paper presents the rationale behind this international partnership, the state of the art of the co-operation and our future plans for expanding this international co-operation.

PREDICT: A simple risk score for clinical severity and long-term prognosis after hospitalization for acute myocardial infarction or unstable angina: the Minnesota heart survey.

BACKGROUND: We evaluated short- and long-term mortality risks in 30- to 74-year-old patients hospitalized for acute myocardial infarction or unstable angina and developed a new score called PREDICT. METHODS AND RESULTS: PREDICT was based on information routinely collected in hospital. Predictors abstracted from hospital record items pertaining to the admission day, including shock, heart failure, ECG findings, cardiovascular disease history, kidney function, and age. Comorbidity was assessed from discharge diagnoses, and mortality was determined from death certificates. For 1985 and 1990 hospitalizations, the 6-year death rate in 6134 patients with 0 to 1 score points was 4%, increasing stepwise to 89% for >/=16 points. Score validity was established by only slightly attenuated mortality prediction in 3570 admissions in 1970 and 1980. When case severity was controlled for, 6-year risk declined 32% between 1970 and 1990. When PREDICT was held constant, 24% of those treated with thrombolysis died in 6 years compared with 31% of those not treated. CONCLUSIONS: The simple PREDICT risk score was a powerful prognosticator of 6-year mortality after hospitalization.

Prevalence of anaemia and iron deficiency in urban Haïtian children two to five years of age.

This study was undertaken to assess the prevalence of anaemia and iron deficiency (ID) in 305 urban Haïtian children, 142 boys and 163 girls from low socioeconomic class, ranging in age from 2 to 5 years. Haemoglobin (Hb), serum ferritin (FERR), serum iron, total iron binding capacity (TIBC), transferrin saturation (TS), and red blood cell indices were measured by standard techniques. Although the means of these indices were within normal range, 58.4 per cent of children had at least one of the measurements in the abnormal range (FERR < 12 micrograms/l, TS < 12, HB < 10.7 g/l in 2 year old and < 10.9 g/dl in 3-5 year old children). The overall prevalence of anaemia (40 per cent) was slightly higher in boys (42 per cent) than in girls (36 per cent). Approximately 45 and 31 per cent of children had FERR < 12 micrograms/l TS < 12 per cent, respectively, with no difference between boys and girls. Despite the decrease in the prevalence of anaemia and ID with age, about one-third of the 5 year old children were either anaemic or iron deficient. Hypochromia and microcytosis were present in 60 and 66 per cent of children respectively. Although ID was the major cause of anaemia, protein-energy malnutrition as judged by low TIBC contributed to the high prevalence of anaemia. Megaloblastic anaemia and haemoglobinopathies did not significantly contribute to the high prevalence of anaemia. The frequency of fruit consumption, hence vitamin C, was lower in anaemic than non-anaemic children. We conclude that the eradication of anaemia and ID in this population will require improvement in overall nutritional status.

Assessment of left ventricular compliance during heart preservation.

There is critical need for a greater number of donor hearts for transplantation. The demand can be relieved, in part, by an extension of preservation time. This necessitates new methods of preservation and development of means to assess the functional condition of the preserved heart. We report a heart-preservation system designed for long-term preservation support and discuss issues specifically related to extended heart preservation. This article presents methodology to assess ventricular compliance and to quantify coronary flow distribution during the use of microperfusion preservation. Ventricular adenosine triphosphate (ATP) concentrations are directly related to the immediate post-preservation function: however, direct measurement of ATP is not clinically available. Based on the premise that ventricular compliance relates directly to the ventricular ATP concentrations, we performed sequential ventricular compliance measurements using a simple left ventricular balloon during a 24 h preservation period. A porcine heart model was employed using a continuous, hypothermic, antegrade, microperfusion system for 24 h and measurements were made at specific intervals during the preservation time. The compliance measurements were ascertained by pressure-volume curves using a flaccid balloon inserted into the left ventricle through the mitral valve. In addition, to assess microvascular function during the preservation interval, regional coronary flow measurements were performed using a microsphere technique. We report that after 12 h of preservation there was a twofold reduction in ventricular compliance which decreased further by fivefold at 18 h. In contrast, there was a time-dependent decrease in left ventricular coronary flow, especially with the left-ventricular subendocardial region significantly decreasing by 50% at 12 h. In conclusion, a simple ventricular-compliance balloon provided a direct measurement of ventricular compliance of the preserved heart which may provide an indirect estimate of the ventricular high-energy phosphates of the preserved heart prior to transplantation.

A decentralized, community-based design for statewide immunization registries in Minnesota.

Incomplete immunization records and an increasingly complex immunization schedule make it difficult for parents and providers to know what shots their children or clients need. Complete and accurate immunization records are needed for day care, sports, camp, and school, but this is difficult--especially when previous immunizations have been received at different clinics. Population-based immunization registries help make complete and accurate records more easily available to parents and health care providers. Registries foster the timely sending of reminder notices for children who are due for immunizations and make it possible for providers to quickly assess immunization rates in their clinic. Public health officials use registries to determine immunization rates, to identify pockets of need where immunization rates are low and to target resources. In Minnesota, over 85% of immunizations are delivered in the private sector. Minnesota is also extensively covered by managed care organizations with an estimated 75% of the total population enrolled in some type of managed care. Strong local community public health agencies in each county also drive local solutions to community needs. These factors and others led to a de-centralized approach to the implementation of registries. The "Minnesota Model" is based on the development of community-based registries which link together local clinics, hospitals, health plans, public health departments, and schools in each region. Each community-based registry is designed to link to a state hub. This decentralized open architecture design is based on standards for data, not hardware or software. The building begins, not by implementing a state registry into which all immunizations are entered, but at the community level. Currently, 38% of Minnesota counties (representing 52% of statewide births) are involved in implementing a community-based registry, and 53% (representing 43% of statewide births) have initiated discussions with private providers. Only 9% of counties (5% of statewide births) have no current registry activity. This paper describes the steps which have been taken towards developing a decentralized statewide immunization information system for Minnesota, based on recommendations put forth by The State Immunization Practices Task Force Work Group on Immunization Registries.

A novel mechanism for cyclosporine: inhibition of myocardial ischemia and reperfusion injury in a heterotopic rabbit heart transplant model.

BACKGROUND: Advances in myocardial preservation techniques and immunosuppressive drug therapy have resulted in heart transplantation as an acceptable treatment for end-stage heart failure. However, excessive periods of global myocardial ischemia followed by reperfusion can progress to irreversible graft injury. It has been reported that cyclosporine A (in addition to its well-characterized immunosuppressive actions) can blunt certain features of ischemia and reperfusion injury. This study was performed to examine the ability of cyclosporine A to attenuate such injury in a model of heart transplantation. METHODS: Twenty rabbit heterotopic transplants were divided into four study groups: (1) 30-minute ischemic control hearts; (2) 30-minute ischemic cyclosporine A-treated hearts; (3) 4-hour ischemic control hearts; and (4) 4-hour ischemic cyclosporine A-treated hearts. A single dose of cyclosporine A (10 mg/kg intravenously) or vehicle was administered to both the donor and recipient rabbits 45 minutes before heart explantation and heart transplantation, respectively. RESULTS: After transplantation and 30 minutes of reperfusion, the 4-hour ischemic control hearts showed a significant (p < 0.01) leftward shift in the left ventricular end-diastolic pressure versus left ventricular volume curve compared with the 30-minute ischemic control hearts. This finding represents higher end-diastolic pressures and incomplete diastolic relaxation caused by ischemia and reperfusion. Cyclosporine A administration to the donor and recipient rabbits resulted in a significant improvement (p < 0.01) in diastolic relaxation (shift in the left ventricular end-diastolic pressure versus left ventricular volume curve back to the right) compared with 4-hour ischemic control hearts. Cyclosporine A-treated hearts also showed significant improvements in the rate of diastolic pressure fall (p < 0.05) and tau (the isovolumetric pressure decay constant) (p < 0.01) compared with ischemic control hearts. CONCLUSIONS: These results indicate that single doses of cyclosporine A to both the donor and recipient inhibit the dysfunction in extent and rate of left ventricular relaxation caused by prolonged global ischemia and reperfusion. Possible mechanisms for cyclosporine A's myocardial protective actions are presented in the discussion.

Simulation of stochastic micropopulation models--IV. SNAPPERS: model implementation for genetic traits.

The current paper concerning stochastic micropopulation simulations describes SNAPPERS, which serves as a framework for simulation models of the genetic transmission of disease. The versions described are implemented using the simulation shell, SUMMERS, which includes the generic commonalities of several micropopulation models. Population members in SNAPPERS move through states related to the individual's status relative to the genotype (phenotype). Features of the model include one or two major loci, polygenic and common familial contribution to the phenotype, assortative mating, and flexibility in defining gene action. The user can select from multiple ascertainment strategies for analysis of simulated families.

Polychotomous multivariate models for coronary heart disease simulation. IV. The impact of physiological aging.

This is an extension of a series of papers dealing with certain models used in the simulation of coronary heart disease. The current study investigates implications of including age as a risk factor in the models discussed in the preceding papers. The effects of using age as a risk factor were investigated in two ways. In one of these, age is interpreted as age of entry into the study; it is similar to the other risk factors in that it is assumed to be constant throughout the study. In the other, age is interpreted as the actual age; thus it increases during the course of simulations. Two polychotomous, multivariate risk functions developed in previous studies, the logistic risk and the Neyman exponential risk, were used to explore the effects of including age as a risk factor. The estimated risk coefficient for age was found to be statistically significant for both functions. The model performance was evaluated by comparing the observational data with outcomes simulated using Monte Carlo techniques. It was found that the logistic risk function failed to describe the observations either with age as a constant or with aging during the simulations. The models including the Neyman exponential risk avoidance fit the data well. The evaluation of the results indicates that aging during the simulations is better than using only the age as the constant value at entry to the study.

Network analytic methods for epidemiological risk assessment.

The authors measure the efficacy of three methods for predicting the time to infection for susceptible individuals in a population undergoing an HIV epidemic. The methods differ in whether they require detailed information of the contact network and whether they require knowledge of the initial source of infection. Efficacy is evaluated using simulations for 20 different contact patterns. Only the risk score that uses both kinds of information accounts for more than 15 per cent of individual variability. The efficacy of this score ranges from 10 per cent in very unstructured populations to 60 per cent for spatially localized contact networks. This improved performance may be explained by the larger fraction of the total variability not due to the disease dynamics. When all variables are dichotomized, the two poorer methods produce odds ratios between 1.4 and 2.3. The odds ratio for the risk score with full information ranges from 2.5 to 17. Risk assessment protocols and intervention programmes are encouraged to assess contact patterns and detect sources of infection.

Simulation of stochastic micropopulation models--I. The SUMMERS simulation shell.

A generic, abstract model and the simulation shell based on it, both called SUMMERS, are used as a framework for the implementation of stochastic micropopulation models; in these, each individual is followed separately while moving through a sequence of states. The shell supports groups of interacting members, individual characteristics and multiple simultaneous activities. Stochastic decisions may be made using Monte Carlo rules. Keywords control the simulations and the reports generated. A sensitivity analysis utility allows assessment of the dependency of outcomes on model features. Extensive use has been made of software engineering techniques. Specializations of SUMMERS are described in subsequent papers.

Simulation of stochastic micropopulation models--III. COGNET: an artificial neural network for visual recognition.

COGNET, based on a neural network first described by Fukushima, demonstrates the relationship between connectionist and other micropopulation models. Its success and physiological orientation led to an implementation using the SUMMERS simulation shell. After self-supervised learning, COGNET uses forward and backward propagation of signals to recognize partial and noisy patterns, and to reconstruct the originals. Stochastic features include variable thresholds for neuronal firing and occasional cell death. The successful implementation of COGNET demonstrates the generality of the concepts embodied in SUMMERS, which in turn promotes the reusability of software and facilitates the extension of computational models in biomedical research. COGNET itself forms a framework for building other physiologically oriented neural network models.

Simulation of stochastic micropopulation models--II. VESPERS: epidemiological model implementations for spread of viral infections.

This second paper concerning stochastic micropopulation simulations describes VESPERS, which can serve as a framework for simulation models of the epidemic spread of infection. The versions described are implemented using the simulation shell, SUMMERS, which includes the generic commonalities of several micropopulation models. Population members in VESPERS move through states related to the individual's status relative to the infective agent. Features of the models include mixing groups, member demographics, susceptibility and infectiousness, and co-circulation of infectious agents. The sensitivity of the simulation outcomes to quantitative features of the model has been analyzed. The user can select reports of desired distributions and averages of simulation outcomes.