[Virtual palliative care : Pilot study of an electronic tool to test cognitive, psychomotor and affective palliative medical and pain therapeutic learning contents during medical training]. / Virtuelle Palliativversorgung : Pilotierung eines elektronischen Tools zur Prüfung kognitiver, psychomotorischer und affektiver palliativmedizinischer und schmerztherapeutischer Lerninhalte während der ärztlichen Ausbildung.

BACKGROUND: This article describes a first use of an electronic case-based assessment tool in undergraduate palliative care education. It describes the development of the tool presenting strengths and shortcomings in order to contribute to an innovative design of assessment tools in medical education. DESIGN AND METHOD: An electronic (virtual) case-based assessment tool (the virtual palliative patient, vPp) was developed. Palliative care levels of knowledge, skills and attitude of students were tested at a computer workplace as a voluntary and non-performance-relevant pilot project at four faculties. RESULTS: On average the students achieved 80% of the points using the vPp tool, which is below the average score of 91% achieved in the regular examination. In particular, the free text task on reflection of dealing with the patient's death wish caused uncertainty, while multiple choice questions and an interactive conversation sequence were perceived as relatively easy. Technical problems were also identified in the evaluation but overall the concept was evaluated positively and establishment as a regular examination or e­learning tool was desired. CONCLUSION: The implementation of an innovative assessment tool in medical education is technically challenging. A coordination with contents of the individual faculties is necessary in order that students do not have a feeling of a lack of preparation. The development of the vPp describes an innovative assessment format. In the long term, all interested faculties could receive a form of toolbox containing the technical framework of the assessment tool, which can then be fed with new contents.

Adult 'fetal-like' erythropoiesis characterizes recovery from bone marrow transplantation.

The transient fetal-like erythropoiesis which appears during recovery from bone marrow transplantation has now been examined at the level of erythroid progenitor cells. A 7-year-old boy with beta +-thalassaemia major was studied during engraftment from his beta-thalassaemia trait sister. Hb F and i antigen rose as expected. Macrocytosis never developed, but red cell size distribution became very heterogeneous. Bone marrow CFU-E and BFU-E were detected by 30 d, prior to the appearance of reticulocytes. Marrow erythroid progenitor cell numbers were normal by 146 d, while those in the blood became normal by 360 d. After transplantation globin synthesis ratios in erythroid colonies were diagnostic of thalassaemia trait, indicating engraftment. Individual erythroid colonies derived from both blood and marrow at all times during reconstitution showed no correlation of G gamma and gamma. Thus the fetal-like stress erythropoiesis of marrow expansion following transplantation was derived from adult and not fetal progenitor cells.

Fetal hemoglobin synthesis in erythroid cultures in hereditary persistence of fetal hemoglobin and beta o-thalassemia.

To determine whether hemoglobin regulation is normal in diseases affecting beta-globin gene expression, globin synthesis was examined in members of a family of a patient with hereditary persistence of fetal hemoglobin/beta o-thalassemia (HPFH/beta o-thal). The HPFH defect is the Ghanian type II, with a deletion from psi beta 1 to at least 20 kb 3' to beta. The beta o-thal gene has the haplotype II restriction enzyme pattern and has the beta 39 nonsense mutation. Erythroid colonies from blood BFU-E were radiolabeled, and globin chains were separated by gel electrophoresis. Colonies from the beta o-thal heterozygote had non-alpha/alpha ratios more balanced than in the reticulocytes. Gamma synthesis was 11% of non-alpha, which is higher than in reticulocytes, but within the range seen in normal adult colonies. Both HPFH heterozygotes produced 20%-30% gamma in erythroid colonies as well as reticulocytes, although non-alpha/alpha was more balanced in the colonies. The HPFH/beta o-thal patient produced 100% gamma in reticulocytes and in colonies. G gamma and gamma-synthetic proportions were not correlated at the individual colony level in the heterozygotes, suggesting that they had "adult" and not "fetal" progenitor cells. The Hb expression of these adult progenitors is presumably modulated normally in vivo in beta o-thal, but the normal decrease in HbF production does not occur in gene deletion HPFH.

Switch from fetal to adult hemoglobin is associated with a change in progenitor cell population.

To examine the switch from fetal to adult hemoglobin at the cellular level, erythroid progenitor cells from newborn infants and adults were cultured in methyl cellulose with erythropoietin. Individual erythroid colonies were labeled with [3H]leucine at various times, and globin synthesis patterns examined by gel electrophoresis and fluorography. The percent gamma- or beta-globin synthesis was determined from the total of gamma + beta, and the percent G gamma from the total of G gamma + A gamma. The nonparametric correlation coefficients of percent G gamma with percent gamma or beta were obtained. Each group of colonies at each time point was examined separately. In colonies from adult blood, the proportion of G gamma-synthesis did not correlate with the proportion of gamma-synthesis. Colonies from newborn blood fell into two groups. Those that developed from relatively mature progenitor cells, and were seen on day 14, showed a strong negative correlation of G gamma with beta-globin synthesis. However, those newborn colonies that developed from immature progenitors, and were seen later in culture (days 17 and 21), showed no correlation of G gamma with beta-synthesis. These findings are compatible with a clonal model for hemoglobin switching. Fetal progenitors, in which G gamma- and beta-syntheses are negatively correlated, are gradually replaced during ontogeny by adult progenitors. The adult progenitors produce more beta (less gamma), and the proportions of G gamma- and gamma- or beta-synthesis are not correlated.