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Technology & Innovation: Handheld Computers For Surgical Logbooks
Technology & Innovation: Handheld Computers For Surgical Logbooks
14 The Journal of Surgery • Volume 2 • Issue 1 • 2004 The Journal of Surgery • Volume 2 • Issue 1 • 2004 59
to change the password. The software then shows you a list of all “Set Access Password”. The software asks you to choose any and anti-CD40L antibodies) have been investigated to prevent Inteleukin-2 receptor blockade
the operations (figure 3). Of course the list begins empty, and to password, which can be as long as you want and contain any ‘signal two’ from being generated since, if signal one is delivered The action of IL-2 can be blocked at its receptor (CD25),
document your first operation, tap the “New” button. As figure 4 combination of letters and numbers. For speed on the wards, in the absence of signal two then antigen specific tolerance is which has lead to the development of two anti-CD25 antibodies,
shows, the “Date” line has already been completed for you, you should stick to numbers because HanDBase provides you with induced.11, 12, 13 There is much ongoing interest in this area. A further basiliximab and daclizumab, produced by genetic engineering.
defaulting to the date on which you began completing the form. a number pad. For security, you should choose a number at least method of inducing tolerance is to encourage deletion of They were developed from mouse monoclonal antibodies specific
You can change the date by tapping on it. The “Patient ID” line is six digits in length, and avoid predictable sequences (like ‘111111’ graft-specific T-cells. Activated T-cells are susceptible to for the chain of the human interleukin-2 receptor, but importantly
empty, waiting for you to add the identification number of your or your date of birth). activation-induced cell death (AICD). The final drug described only the variable domains of the light and heavy chains of
patient. Tap on the dotted line and start writing. below, rapamycin, promotes the susceptibility of activated T-cells basiliximab, and the three complementarity-determining regions
Advanced features to this apoptotic process, and this attractive method of inducing of each variable domain in daclizumab are of mouse origin.24, 25
The rest of the form is self-explanatory, and similar to the paper The full advantages of using electronic logbooks become apparent tolerance is also under intense scrutiny.14 This means that both these antibodies are much less likely to
forms from the surgical Royal Colleges (figures 5-6). However when you have to audit your surgical outcomes or summarise your be seen as a foreign protein and thus be removed by the patient’s
the more effort you put into the logbook, the more effort it can surgical experiences. HanDBase allows you to create reports, Immunosuppresive Drugs immune system. Trials have shown that these drugs both reduce
save you. For example, you can enter the operation name by search the data or highlight particular operations. The user acute rejection.26
writing on the dotted line to the right of “Operation” (figure 4). manual contains full documentation of these features and you Antimetabolites
However if you tap on the triangle to the left of “Operation”, a list should read the sections about “Search Database”, “Filters” and Azathioprine inhibits purine metabolism, by competitively mTOR Inhibitors
pops up with “Edit Popup List” at the bottom. If you tap on “Edit “Reports”. This software gives you more tools than Osler ever had antagonising an enzyme central to purine synthesis.15 More Successful interaction of IL-2 with its receptor leads to the
Popup List”, you have the opportunity to edit that list (figure 7). access to. recently, we have had access to the drug MMF, which is an ester generation of a signal within the cell, starting the cell cycle and
Add the names of the operations that you do most commonly. For prodrug with higher bioavailability than its active agent, leading to proliferation.27 Increasing evidence suggests that
example, if you are an ophthalmic surgeon, you could tap “New”, Conflicting Interests mycophenolic acid (MPA).16 This drug acts in a far more targeted mTOR, a regulatory kinase, acts as a central controller in this,
write “Drainage of orbit” (figure 8), tap “OK” and then “OK” I am the author of the book Handheld Computers for Doctors and way than azathioprine, acting on the enzyme inosine sensing cellular environment (mitogenic stimulation) and
again. From then on, if you tap on the triangle to the left of the accompanying website www.handheldsfordoctors.com which monophosphate (IMP) dehydrogenase, which converts IMP to a regulating translation initiation through the eukaryotic initiation
“Operation” you will find “Drainage of orbit” is included in the sells handheld computers. precursor of guanine. This pathway is important in nucleotide factor 4E, and ribosomal p70 S6 kinase pathways, thus allowing
list (figure 9). If you tap on that, “Drainage of orbit” is automati- synthesis in lymphocytes, but less so in other cells Furthermore the cell to enter the cell cycle9, 27 Rapamycin (now called
cally filled in on the dotted line (figure 10). It is worth spending
References MPA is almost five times more potent in inhibiting the isotype of sirolimus) inhibits this process. It is not yet clear how best to use
a little time tailoring all the lists (including “Operation” and 1. Bliss M. William Osler: A Life in Medicine. Oxford: Oxford University IMP dehydrogenase present in activated compared to resting this agent. We do know that adding this drug to the regimen of
“Complication”) to your speciality. Press 1999. lymphocytes. Studies have shown that MMF decreases the ciclosporin and prednisolone decreases acute rejection28, and it
2. Al-Ubaydli M. Shop for Handhelds [online]. Available: http://www.handheldsfor
doctors.com/shop [accessed 1.1.2004]
frequency and severity of rejection compared to azathioprine.16 can also be substituted for ciclosporin29, avoiding the
Security 3. Bush SG. Better than Pocket Office [online]? Available: So far this difference has not been shown to improve graft nephrotoxicity encountered with this drug.
The logbook does not allow you to enter a patient’s name. I did http://www.brighthand.com/article/Office_comparison [accessed 1.1.2004] survival, though it is hard to perform a suitably powered study to
this for security. First, cataloging identifiable data about your 4. Hildebrandt SS. HanDBase from DDH Software [online]. Available:
http://www.pdacortex.com/HanDbase_Review.htm [accessed 1.1.2004]
detect this difference.17 However MMF’s effects may in the long Face, Hand and Other Composite
patients makes you subject to the Data Protection Act. Although it term be shown to improve renal allograft survival.18
5. Al-Ubaydli M. HanDBase 3.0 Review [online]. Available: http://www.handheld Tissue (CT) Transplantation
is reasonably straight-forward to comply10, in the case of a fordoctors.com/learn/organisation/handbase3review.htm [accessed 1.1.2004]
The arguments against performing a face transplant are similar to
logbook there is not much to gain. Furthermore the risks of data 6. Al-Ubaydli M. Handheld Computers for Doctors. London: John Wiley and Sons
Corticosteroids
2003. Chapter 13. Pages 75-84. those applied to hand transplantation. The performing of a hand
falling into the wrong hands (if, for example, you lost your Prednisolone and methylprednisolone are both still used in
7. DDH Software Inc. HanDBase [online]. Available: transplant was not uncontroversial6,30,31 many arguing that the risk
machine) are too great. http://www.ddhsoftware.com/handbase.html [accessed 1.1.2004] transplantation. They function by reducing gene activation,
8. pdaMD.com. Installing Sofware [online].
of long term adverse effects of immunosuppression did not
Available: http://www.pdamd.com/vertical/tutorials/guides/installsoftware.xml
which occurs if the signal induced by engagement of the T-cell outweigh the benefits of gaining a hand. Indeed the first recipient
As an additional security measure the logbook is encrypted and receptor is successfully transduced to the nucleus.3 Expression of
[accessed 1.1.2004] of such a transplant was unable to tolerate the side effects of his
password-protected. The encryption means that every time you 9. Al-Ubaydli M. Surgical logbook [online]. Available: genes that lead to the production of pro-inflammatory cytokines drug regime and thus lost his transplant.31 However, as described
stop using the logbook HanDBase converts the data into a format http://www.handheldsfordoctors.com/learn/organisation/surgicallogbook.htm
re among those inhibited by steroids, thus reducing T cell
[accessed 1.1.2004] above, over 20 hand transplants have been performed to date,
that can only be decoded if the right password is entered. It is activation. How exactly steroids do this is only now becoming
10. Information Commissioner. Welcome to the Information Commissioner’s Office and so far only two have been lost. The longest surviving hand
important that you choose a good password. At the beginning there [online]. http://www.informationcommissioner.gov.uk/ [accessed 1.1.2004] clearer and is thought to be based mainly on interference transplant has been in situ for more than five years, with reports in
is no password so you must change this. Tap “DB Properties” with transcription factors, such as activator protein-1 (AP-1) the media of excellent function (CNN website, 28th February
in the “Option” menu (figure 11) then tap “Security” and and nuclear factor kappa B (NF-kappa B).3 2004). This has become possible because of the developments
both in understanding the rejection process and also the
The reduction of lymphocyte proliferation seen with the use of continuing work in developing new drugs that target this process,
these drugs is likely to be due to the reduction of cytokine as well as improved microsurgical technique.30
production. Reduced expression of genes coding for adhesion
molecules leads to reduced leukocyte migration.19, 20 However, The regime used for hand transplants (tacrolimus/MMF/
their long term use has a well known plethora of adverse effects prednisolone) works by blocking the signals that generate an
(such as Cushing’s syndrome, osteoporosis, cataracts, peptic immune response in three different areas as described above.
ulcers, glucose intolerance, hypercholesterolemia, skin fragility, The fact that successful hand transplants have occurred
and adrenal suppression) and many units thus aim relatively demonstrates well the power of modern immunosuppressive
rapidly to wean patients off corticosteroids. drugs. The immunogenicity of composite tissues, particularly skin
should not be underestimated, due to the presence within it of a
Calcineurin Inhibitors. large number of cells of the immune system, including high
Calcineurin is a phosphatase which is activated if an antigen numbers of dendritic cells, which easily trigger an immune
is recognised by a T-cell. It allows a promoter called “nuclear response.33 Furthermore it can be argued that there is a much more
factor of activated T cells” (NFAT) to enter the nucleus and limited functional reserve in composite tissues, so any rejection
promote the transcription of several cytokine genes, including episode may have more obvious effects than in solid organ
IL-2. By inhibiting this enzyme, ciclosporin and, more recently, transplants30
tacrolimus prevent this from occurring.10, 21 Thus the message
that the T-cell receptor has recognised antigen does not High levels of immunosuppression are going to have long term
reach the nucleus. adverse effects, as described above, and thus the development of
mechanisms inducing tolerance would greatly benefit face
Both drugs are in use, but evidence suggests that tacrolimus transplantation. Work in small animal models has shown that it is
is associated with a lower incidence of acute rejection.22, 23 possible to generate tolerance, though so far this has not been
They have differing adverse effects, but both require monitoring reproduced in larger animal models. Obviously the ability
of their blood levels, due to their narrow therapeutic windows23 to induce tolerance to transplanted composite tissues would help
overcome the scepticism that many in the transplant community
have towards composite tissue transplantation. The final point to
Figures 1-11
60 The Journal of Surgery • Volume 2 • Issue 1 • 2004 The Journal of Surgery • Volume 2 • Issue 1 • 2004 13