Requirements engineering: the key to designing complex medical systems

A variety of business systems, clinical work systems, instrumentation systems, information systems, infrastructure systems, and management systems interact to make the modern healthcare facility work. The key to designing for such a system is systems engineering, a skill often little appreciated among clinical engineers. At the heart of systems engineering is requirements engineering and management (REAM), which is defined as "the process of discovering, documenting and managing systems requirements." The principal activities of REAM include eliciting, understanding, negotiating, describing, validating, and managing system requirements. When REAM is done improperly, the resulting system will be satisfactory only if chance intervenes. Well-done REAM is likely to bring the project in on time, under budget, and at full performance.     

Theme C: Medical information systems and databases – results and future work

This paper presents the activities of the theme C “medical information systems and databases” in the GDR Stic Santé. Six one-day workshops have been organized during the period 2011–2012. They were devoted to 1) sharing anatomical and physiological object models for simulation of clinical medical images, 2) advantages and limitations of datawarehouse for biological data, 3) medical information engineering, 4) systems for sharing medical images for research, 5) knowledge engineering for semantic interoperability in e-health applications, and 6) using context in health. In the future, our activities will continue with a specific interest on information systems for translational medicine and the role of electronic healthcare reports in decision-making. Workshops with other research groups will be organized in particular with the e-health research group.     

A window into biocatalysis and biotransformations

Eight papers were presented in this year's symposium "Advances in Biocatalysis" at the 232nd ACS National Meeting, accentuating the most recent development in biocatalysis. Researchers from both industry and academia are addressing several fundamental problems in biocatalysis, including the limited number of commercially available enzymes that can be provided in bulk quantities, the limited enzyme stability and activity in nonaqueous environments, and the permeability issue and cell localization problems in whole-cell systems. A trend that can be discerned from these eight talks is the infusion of new tools and technologies in addressing various challenges facing biocatalysis. Nanotechnology, bioinformatics, cellular membrane engineering and metabolic engineering (for engineering whole-cell catalysts), and protein engineering (to improve enzymes and create novel enzymes) are becoming more routinely used in research laboratories and are providing satisfactory solutions to the problems in biocatalysis. Significant progress in various aspects of biocatalysis from discovery to industrial applications was highlighted in this symposium.     

BeadArray-based solutions for enabling the promise of pharmacogenomics

A "one-size-fits-all" approach continues to characterize today's healthcare paradigm. But emergent rules, information, genomics tools, and economics are driving a fundamental and inevitable shift to a more personalized world of medicine. In this new world, the interests of insurers, regulators, suppliers, healthcare providers, and most important, patients, will have converged. The new goal will be the right treatment for the right individual at the right time. In this world, personalized medicine, through pharmacogenomics (PGx), will be the new healthcare paradigm. We will briefly examine healthcare trends and current opportunities for PGx development. We will then demonstrate how microarray technologies-among them bead-based approaches-have emerged as a key enabler for bringing home the promise of PGx.     

Redesigning healthcare: The 2.4 billion euro question?

Although it has been possible to transfer electrocardiograms via a phone line for more than 100 years, use of internet-based patient monitoring and communication systems in daily care is uncommon. Despite the introduction of numerous health-monitoring devices, and despite most patients having internet access, the implementation of individualised healthcare services is still limited. On the other hand, hospitals have invested heavily in massive information systems offering limited value for money and connectivity. However, the consumer market for personal healthcare devices is developing rapidly and with the current healthcare-related investments by tech companies it can be expected that the way healthcare is provided will change dramatically. Although a variety of initiatives under the banner of ‘e-Health’ are deployed, most are characterised by either industry-driven developments without proven clinical effectiveness or individual initiatives lacking the embedding within the traditional organisations. However, the introduction of numerous smart devices and internet-based technologies facilitates the fundamental redesign of healthcare based on the principle of achieving the best possible care for the individual patient at the lowest possible cost. Conclusion The way healthcare is delivered will change, but to what degree healthcare professionals together with patients will be able to redesign healthcare in a structured manner is still a question.     

Cancer therapy with genetically-modified T cells for the treatment of melanoma

The aim of this review is to acquaint the reader with the concept of T cell receptor (TCR) gene therapy for metastatic melanoma. We first review antigen choice, followed by gene delivery technology and, finally, we discuss selected clinical applications. To be successful, TCR gene therapy must combine multiple elements and research disciplines. First, there is a need for an understanding of tumor immunology because this is essential in proper antigen choice. Second, gene therapy is a technology-driven field and cutting edge knowledge of protein engineering and gene delivery methods are indispensable. Finally, a dedicated team of physician/scientists and healthcare providers is fundamental to clinical success. TCR gene therapy is now a realistic treatment option for metastatic melanoma. Both tumor regression and on-target/off-tumor toxicities have been observed, which emphasizes the experimental nature of this approach. As with any new medical procedure, future large-scale randomized trials will be necessary to validate this approach, and these are within reason in the next few years. This article is a US Government work and is in the public domain in the USA.     

Are engineers unsung heroes of medical progress?: the historic bond between physics,engineering, and medicine

This review traces the heretofore unsung hero role of engineering in the evolution of today's healthcare and the growing bond between physics, engineering, and medicine. It recognizes the debt owed to the various specialties of healthcare engineering, especially the bioengineers who contribute not only to a better understanding of basic physiologic and pathologic processes but also to the development and application of technology and the adaptation of new engineering discoveries to medicine. In the past half-millennium, the fields of physics, engineering, and medicine have made a large number of seminal contributions to each other, resulting in ever-advancing healthcare methodologies, although only a precious few remain identified by the originators' names. In this review, 3 engineers are cited in detail for their milestone contributions to medical progress: Roentgen in radiology, Bovie in electrosurgery, and, more recently, Greatbatch in implantable cardiac pacemakers. Future horizons in medicine appear to be ever more attainable because of the synergism between the physical and biological sciences.     

ADVANCE DIRECTIVES IN TURKEY'S CULTURAL CONTEXT: EXAMINING THE POTENTIAL BENEFITS FOR THE IMPLEMENTATION OF PATIENT RIGHTS

Advance directives are not a part of the healthcare service in Turkey. This may be related with the fact that paternalism is common among the healthcare professionals in the country, and patients are not yet integrated in the decision‐making process adequately. However, starting from the enactment of the Regulation of Patient Rights in 1998, this situation started to change. While the paternalist tradition still appears to be strong in Turkey, the Ministry of Health has been taking concrete measures in the recent years to ensure that patient rights are implemented in healthcare practice. Therefore, Turkey now seems to be in a transitional period where a move towards a more patient‐autonomy centred approach is being supported by the regulatory authorities, as well as the academic circles and the public at large. In the light of this background, this paper aims to examine the potential benefits of advance directives, particularly with regard to their possible effect in the clinical decision‐making process of Turkey's context. It will be argued that advance directives, if correctly understood and implemented in the right settings, may be beneficial, particularly for improving communication between patients and healthcare professionals and for implementing of the right to refuse treatment.     

血小板体外质量评价研究进展

血小板输注是现代医学治疗的一项有效措施,近年来在临床上的应用日益普遍。血小板的临床输注效果与在体外的保存质量密切相关。我们简要介绍目前评价血小板体外质量的主要实验方法和仪器,以及它们在临床使用中的优缺点。     

Translational genomics in personalized medicine – scientific challenges en route to clinical practice

Background

In the area of omics and translational bio(medical)sciences, there is an increasing need to integrate, normalize, analyze, store and protect genomics data. Large datasets and scientific knowledge are rationally combined into valuable clinical information that ultimately will benefit human healthcare and are en route to clinical practice. Data from biomarker discovery and Next Generation Sequencing (NGS) are very valuable and will combine in comprehensive analyses to stratify medicine and guide therapy planning and ultimately benefit patients. However, the combination into useful and applicable information and knowledge is not trivial.

NGS in personalized medicine

Personalized medicine generally promises to result in both higher quality in treatment for individual patients and in lower costs in health care since patients will be offered only such therapies that are more effective for them and treatments that will not be safe or effective will be avoided. Recent advancements in biomedical and genomic sciences have paved the way to translate such research into clinical practice and health policies. However, the move towards greater personalization of medicine also comes along with challenges in the development of novel diagnostic and therapeutic tools in a complex framework that assumes that the use of genomic information is part of a translational continuum, which spans from basic to clinical research, preclinical and clinical trials, to policy research and the analysis of health and economic outcomes. The use of next-generation genomic technologies to improve the quality of life and efficiency of healthcare delivered to patients has become a mainstay theme in the field as benefits derived from such approaches include reducing a patient’s need to go through ineffective therapies, lowering side- and off-target effects of drugs, prescribing prophylactic therapies before acute exacerbations, and reducing expenditures.

Economic challenges

As such, personalized medicine promises to increase the quality of clinical care and, in some cases, to decrease health care costs. Besides the scientific challenges, there are several economic hurdles. For instance, healthcare providers need to know, whether the approach of personalized healthcare is affordable and worth the expenses. In addition, the economic rationale of personalized healthcare includes not only the reduction of the high expense of hospitalizations, the predictive diagnostics that will help to reduce cost through prevention or the increased efficacy of personalized therapies needs to offset prices of drugs. There are also several factors that influence payer adoption, coverage and reimbursement; the strength of evidence drives payers‘ decisions about coverage and reimbursement, varies widely depending on the personalized healthcare technology applied and regulation and cost-effectiveness seem to be increasingly associated with reimbursement, which is strongly influenced by professional society guidelines. In general, we see the following main obstacles to the advancement of personalized medicine: (i) the scientific challenges (a poor understanding of molecular mechanisms or a lack of molecular markers associated with some diseases, for example), (ii) the economic challenges (poorly aligned incentives), and (iii) operational issues in public healthcare systems. The operational issues can often be largely resolved within a particular stakeholder group, but correcting the incentive structure and modifying the relationships between stakeholders is more complex.

En route to clinical practice

This article focuses on the scientific difficulties that remain to translate genomics technologies into clinical practice and reviews recent technological advances in genomics and the challenges and potential benefits of translating this knowledge into clinical practice, with a particular focus on their applications in oncology.

Electronic supplementary material

The online version of this article (doi:10.1186/1877-6566-6-2) contains supplementary material, which is available to authorized users.     

The year of transparency: measuring quality of cardiac care

The assessment of quality of care is becoming increasingly important in healthcare, both globally and in the Netherlands. The Dutch Minister of Health declared 2015 to be the year of transparency, thereby aiming to improve quality of care by transparent reporting of outcome data. With the increasing importance of transparency, knowledge on quality measurement will be essential for a cardiologist in daily clinical care. To that end, this paper provides a comprehensive overview of the Dutch healthcare structure, quality indicators and the current and future assessment of quality of cardiac care in the Netherlands.     

Molecular mechanism of protein folding in the cell

F.-Ulrich Hartl and Arthur Horwich will share this year's Lasker Basic Medical Science Award for the discovery of the cell's protein-folding machinery, exemplified by cage-like structures that convert newly synthesized proteins into their biologically active forms. Their fundamental findings reveal mechanisms that operate in normal physiologic processes and help to explain the problems that arise in diseases of protein folding.     

公私合营模式下医疗机构服务外包的发展和规范

医疗机构为集中精力提供高效、专业临床诊疗服务,将其非临床诊疗业务、临床支持业务等外包给第三方专业机构。同时,随着国家鼓励公私合营模式发展的政策不断完善,医疗机构服务外包作为公私合营模式在医疗服务供给领域的实践体现具有巨大发展潜力。文章旨在通过分析我国医疗机构服务外包的现状,为其健康发展提供相应的政策建议。     

Leukocyte adhesion and recruitment, and alpha-1-antitrypsin deficiency: a report from ATS 2001, May 18-23, San Francisco

The program at this year's American Thoracic Society international conference included over 300 scientific and clinical symposia. In this report I have reviewed the data presented on two important areas of lung inflammation, namely leukocyte recruitment and alpha-1-antitrypsin deficiency. Highlights included work from a number of groups identifying the contribution of specific leukocyte adhesion molecules (CD18, CD11a and vascular cell adhesion molecule-1) which varied according to the site and nature of the initial inflammatory stimulus. In addition work was presented examining the contribution of various chemoattractants to the process of leukocyte recruitment in chronic obstructive pulmonary disease, with leukotriene B₄ in particular appearing to play a major role. In alpha-1-antitrypsin deficiency other molecules may also be important and work was presented demonstrating the pro-inflammatory potential of alpha-1-antitrypsin polymers in the lungs of these patients. These advances in the understanding of the basic mechanisms of inflammation will, in the future, allow the development of novel anti-inflammatory therapies for a variety of lung diseases.     

REEXAMINATION OF THE ETHICS OF PLACEBO USE IN CLINICAL PRACTICE

A placebo is a substance or intervention believed to be inactive, but is administered by the healthcare professional as if it was an active medication. Unlike standard treatments, clinical use of placebo usually involves deception and is therefore ethically problematic. Our attitudes toward the clinical use of placebo, which inevitably includes deception or withholding information, have a tremendous effect on our practice regarding truth‐telling and informed consent. A casual attitude towards it weakens the current practice based on shared decision‐making and mutual trust between patients and healthcare professionals. Issues concerning the clinical use of placebo are thus intimately related to patient‐provider relationships, the public's trust in medicine, and medical education. A review of recent survey studies suggests that the clinical use of placebo appears to be fairly well accepted among healthcare professionals and is common in clinical settings in various countries. However, we think that an ethical discussion is urgently needed because of its controversial nature. If judged to be ethically wrong, the practice should end. In the present paper, we discuss the ethicality of the clinical use of placebo with deception and argue against it, concluding that it is unethical and should be banned. We will show that most arguments in favor of the clinical use of placebo can be refuted and are therefore incorrect or weak. These arguments will be presented and examined individually. Finally, we will briefly consider issues relevant to the clinical use of placebo without deception.     

Novel genetic modules encoding high-level antibiotic-free protein expression in probiotic lactobacilli

Lactobacilli are ubiquitous in nature, often beneficially associated with animals as commensals and probiotics, and are extensively used in food fermentation. Due to this close-knit association, there is considerable interest to engineer them for healthcare applications in both humans and animals, for which high-performance and versatile genetic parts are greatly desired. For the first time, we describe two genetic modules in Lactiplantibacillus plantarum that achieve high-level gene expression using plasmids that can be retained without antibiotics, bacteriocins or genomic manipulations. These include (i) a promoter, P_tlpA, from a phylogenetically distant bacterium, Salmonella typhimurium, which drives up to 5-fold higher level of gene expression compared to previously reported promoters and (ii) multiple toxin-antitoxin systems as a self-contained and easy-to-implement plasmid retention strategy that facilitates the engineering of tuneable transient genetically modified organisms. These modules and the fundamental factors underlying their functionality that are described in this work will greatly contribute to expanding the genetic programmability of lactobacilli for healthcare applications.     

Biomedical engineering continues to make the future

Biomedical engineering (BME) continues to make the future, not just respond to the present, by anticipating the needs of interface engineering and clinical medicine. In many respects, BME is the educational mode of the future, fostering collaboration among disciplines at its core by building on basic concepts in engineering and biology. We strive to educate where the needs, opportunities, and jobs are and will be in the future. The bridge between engineering, biology, and medicine is a growing link, and there is no sign that this interface will slow. With an aging population, dynamic changes in health care, as well as global economies and related themes upon us, we are only at the very beginning of the impact that BME will have on medicine and the quality of life. Those of us in BME are excited to be setting this agenda and welcome your participation. In part, this is why we have designed our BME major to cover both the depth and breadth, always a challenge, but one that we are committed to. The depth of the design projects, research experience, coursework, study abroad options, and internships all convenes to establish a solid foundation for our students as they embark on their career paths.