Polycystic Pancreas
April 2016 199

MBBSAmey D Sonavane
Department of Gastroenterology
Bombay Hospital and Institute of Medical Sciences
MumbaiIndia

DM, DNB, MD, FACGDeepak N Amarapurkar
Department of Gastroenterology
Bombay Hospital and Institute of Medical Sciences
MumbaiIndia

MBBSAnjali D Amarapurkar
Department of Pathology
BYL Nair Charitable Hospital and Topiwala National Medical College
MumbaiIndia

Polycystic Pancreas

REPORTS JOURNAL acgcasereports.gi.org ACG Case Reports Journal |
3April 2016 19910.14309/crj.2016.49
Polycystic disease of the pancreas is a very rare entity with very few cases reported in the literature. We report a symptomatic case of polycystic pancreas associated with pheochromocytoma that was treated surgically.

Introduction

Polycystic disease of the pancreas is a rare entity with an unknown incidence. Polycystic disease of the pancreas or dysontogenetic cysts of the pancreas can occur with other cysts, especially those of the kidneys, liver, central nervous system, and spleen. Pancreatic cysts are found in 10% of patients with polycystic kidney disease, which suggests an etiologic connection between the different cyst types. 1 The tail or neck of the pancreas (62%) is the most common site for true cysts. Pancreatic cysts can be classified as retention cysts, proliferative cysts, cystic adenoma, cystic epitheliomata, hydatid cysts, congenital cysts, hemorrhagic cysts, or pseudocysts. 2

Case Report

A 32-year-old woman presented with a painless epigastric lump that had progressively grown over 8 years to a size of 9 x 10 x 2 cm. She complained of early satiety, severe loss of appetite, and a 7-kg weight loss. She was recently diagnosed with diabetes mellitus and was on insulin. Transabdominal ultrasound revealed a diffuse atrophic pancreas with dilated main pancreatic duct, along with a 13.5 x 12.8-cm walled-off cystic collection near the pancreatic head, suggestive of a large pseudocyst. It also revealed a simple left thin-walled ovarian cyst (4.5 x 2.5 cm). Abdominal computed tomography (CT) with angiogram revealed a bulky pancreas with variably sized cystic lesions and multiple calcifications. A 3.5 x 2.9 x 4.7-cm partially necrotic lesion was detected in the right adrenal gland. Abdominal magnetic resonance imaging (MRI) showed innumerable cystic lesions of variable sizes diffusely involving the pancreas, almost completely replacing the parenchyma ( Figure 1). The largest cystic lesion was exophytic, measuring 11 x 8.3 x 10 cm ( Figure 2). The lesions resulted in compression and the displacement of the stomach and duodenum. The right adrenal mass was heterogenous and contained nodular irregular cystic/necrotic areas, highly suggestive of pheochromocytoma. There was no evidence of concomitant polycystic kidney disease. Brain CT was normal, and no family history of Von Hippel Lindau disease was reported.

Liver values, renal values, serum carcino-embryonic antigen (CEA), CA 19-9 levels, and plasma level of free metanephrines were normal. Her 24-hour urinary noradrenaline and 24-hour urinary vinyl mandellic acid values were elevated at 237.8 µg and 82 mg, respectively. Fluid resulting from transabdominal ultrasound-guided percutaneous fluid aspiration of the cysts revealed normal amylase, CEA, and CA 19-9 levels, and cytology was negative for malignancy. A gastroscopy revealed extrinsic compression over the stomach and duodenum with significant gastric residue and distorted gastric anatomy. An endoscopic retrograde cholangiopancreatography (ERCP) revealed an irregular pancreatic duct without connection to the cysts. She underwent right adrenalectomy and deroofing of the pancreatic cysts (Figure 3). Histopathology of the pancreatic cyst wall revealed multiple cystic spaces with benign epithelial lining suggestive of polycystic disease of the pancreas ( Figure  4). Histopathological examination of the 30-g right adrenal mass revealed pheochromocytoma. Her hospital recovery was uneventful and she was asymptomatic at 6-month follow-up.

Discussion

Polycystic disease of the pancreas is a very rare entity with very few cases reported in the literature. Bile and pancreatic secretions are transported to the gut lumen by widespread and complex networks of ducts in the liver and pancreas. The endoderm germ layer lining the primitive gut gives rise to the epithelial cells that form the ductal trees. Anomalous development of these duct systems (ducts with dramatically enlarged lumen and multiple cysts) can lead to polycystic disease in both liver and pancreas. True cysts develop as a result of developmental defects that cause sequestration of primitive pancreatic ducts. It was recently demonstrated that Forkhead box-containing protein, O-subfamily (FoxO1) gain of function in the pancreas can lead to diabetes, polycystic pancreas, and islet hypervascularization. 3 Detailed histopathology of the cyst lining shows a lack of the primary cilia that are normally found on pancreatic ductal epithelial cells. This is comparable to the absent cilia seen in polycystic kidney disease. Molecular analysis shows that in a hepatocyte nuclear factor 6 (HNF-6)-deficient pancreas, the intra-and interlobular ducts were abnormal, causing multilayered epithelia with atypical cellular polarity, absence of primary cilia, and development of cysts. 4 Ciliopathy has been thus associated with cyst formation in various organs including kidney, liver, and pancreas.

Congenital pancreatic cysts are largely asymptomatic, but can present with abdominal distension, vague abdominal pain, vomiting, jaundice, or pancreatitis. [5][6][7] Ultrasonography is particularly valuable for cystic/solid differentiation, and a color Doppler flow can demonstrate the vascular nature of lesions. 8 Cross-sectional imaging is eventually important in the characterization and localization of the cysts. MRI is preferred over CT as it can establish the relationship between a cyst and surrounding tissues, along with extensions of a cyst.   Publish your work in ACG Case Reports Journal ACG Case Reports Journal is a peer-reviewed, open-access publication that provides GI fellows, private practice clinicians, and other members of the health care team an opportunity to share interesting case reports with their peers and with leaders in the field. Visit http://acgcasereports.gi.org for submission guidelines. Submit your manuscript online at http://mc.manuscriptcentral.com/acgcr.

Disclosures

Author contributions: AD Sonavane gathered the data, wrote the manuscript, and is the article guarantor. DN Amarapurkar edited the manuscript. AD Amarapurkar provided the histopathological image.

ACG
Case Rep J 2016;3(3):199-201. doi:10.14309/crj.2016.49. Published online: April 15, 2016. Correspondence: Amey Sonavane, Bombay Hospital and Institute of Medical Sciences, Gastroenterology, Mumbai, Maharashtra, India (firstname.lastname@example.com). Copyright: © 2016 Sonavane et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.

Figure 1 .
1Abdominal MRI showing innumerable cystic lesions of variable sizes diffusely involving the pancreas, almost completely replacing the parenchyma.

Figure 2 .
2Abdominal MRI showing the largest cystic lesion (11 x 8.3 x 10 cm), which was exophytic.

Figure 3 .
3Surgical specimen of the large polycystic lesion.

Figure 4 .
4H&E stain of the pancreatic cyst wall showing multiple cystic spaces with benign epithelial lining (arrow) suggestive of polycystic disease of the pancreas (100x magnification).

Distinguishing between congenital and acquired cysts can be difficult. Clinical history in addition to radiological, and histopathological features can facilitate this differentiation. Solitary congenital cysts are rare. Multiple congenital pancreatic cysts are usually associated with other congenital anomalies, frequently polycystic kidney disease and cysts of the liver, lung, and central nervous system. Congenital cysts can be differentiated from the more common pseudocysts by the existence of a true columnar or cuboidal epithelial lining. Pseudocysts often follow bouts of acute pancreatitis, and the cyst fluid is rich in pancreatic enzymes.Preoperative assessment by MRI or CT can help differentiate benign from malignant pancreatic cysts. Characteristics suspicious of malignancy include peripheral calcification, thick irregular cyst wall, main pancreatic duct dilatation, mural nodules, and enlarged nodes. Benign cysts are characterized by thin walls (unless infected) and usually spare the pancreatic duct. Unfortunately, there is no way to precisely distinguish these lesions radiologically.9 Symptomatic cysts, advanced age, and rapidly increasing size of the cysts are indicators for surgical intervention.10 Sonavane et al

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Polycystic Pancreas

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ACG Case Reports Journal | Volume 3 | Issue 3 | April 2016

Financial disclosure: None to report.Informed consent was obtained for this case report.Received July 5, 2015; Accepted December 9, 2015
Polycystic disease of the pancreas (dysontogenetic cysts): Report of a case with partial pancreatectomy. K K Nygaard, W Walters, Ann Surg. 1061Nygaard KK, Walters W. Polycystic disease of the pancreas (dysonto- genetic cysts): Report of a case with partial pancreatectomy. Ann Surg. 1937;106(1):49-53.

Surgery of the pancreas at hospital from 1918 to 1928. A Stillman, Ann Surg. 901Stillman A. Surgery of the pancreas at hospital from 1918 to 1928. Ann Surg. 1929;90(1):58-64.

FoxO1 gain of function in the pancreas causes glucose intolerance, polycystic pancreas, and islet hypervascularization. O Kikuchi, M Kobayashi, K Amano, PLoS One. 7232249Kikuchi O, Kobayashi M, Amano K, et al. FoxO1 gain of function in the pancreas causes glucose intolerance, polycystic pancreas, and islet hy- pervascularization. PLoS One. 2012;7(2):e32249.

Of cilia and cysts: Modeling pancreatic polycystic disease. K H Kaestner, Gastroenterology. 1303Kaestner KH. Of cilia and cysts: Modeling pancreatic polycystic disease. Gastroenterology. 2006;130(3):926-8.

A rare isolated polycystic pancreatic disease. Radiation free diagnostic protocol in selected cases. D A Dhar, T Suchi, S Garg, V K Dixit, India J Endocrinol Metab. 166Dhar DA, Suchi T, Garg S, Dixit VK. A rare isolated polycystic pancreatic disease. Radiation free diagnostic protocol in selected cases. India J En- docrinol Metab. 2012;16(6):1054-6.

Disorders of the Pancreas. Essentials of Pediatric Surgery. M I Rowe, J A O'neill, Jr, J L Grosfeld, St. Louis, MO: Mosby Year BookRowe MI, O'Neill JA Jr, Grosfeld JL, et al., eds. Disorders of the Pan- creas. Essentials of Pediatric Surgery. St. Louis, MO: Mosby Year Book; 1995:663-74.

Congenital cyst of the pancreas: Antenatal diagnosis. P Daher, N Diab, I Melki, Eur J Pediatr Surg. 63Daher P, Diab N, Melki I, et al. Congenital cyst of the pancreas: Antenatal diagnosis. Eur J Pediatr Surg. 1996;6(3):180-2.

Congenital true pancreatic cysts in young adults: Case report and literature review. R Casadei, O Campione, V M Greco, D Marrano, Pancreas. 124Casadei R, Campione O, Greco VM, Marrano D. Congenital true pancre- atic cysts in young adults: Case report and literature review. Pancreas. 1996;12(4):419-21.

Diagnosis and management of cystic pancreatic lesions. D V Sahani, A Kambadakone, M Macari, Am J Roentgenol. 2002Sahani DV, Kambadakone A, Macari M, et al. Diagnosis and management of cystic pancreatic lesions. Am J Roentgenol. 2013;200(2):343-354.

Cystic pancreatic neoplasms: Observe or operate. K S Spinelli, T E Fromwiller, R A Daniel, Ann Surg. 2395Spinelli KS, Fromwiller TE, Daniel RA, et al. Cystic pancreatic neoplasms: Observe or operate. Ann Surg. 2004;239(5):651-659.


Open Access BMC Research Notes

Pammla Petrucka
University of Saskatchewan
4400 4th Avenue #100S4T 0H8ReginaSKCanada

Sandra Bassendowski
University of Saskatchewan
4400 4th Avenue #100S4T 0H8ReginaSKCanada

Marie Dietrich-Leurer
University of Saskatchewan
4400 4th Avenue #100S4T 0H8ReginaSKCanada

Cara Spence-Gress
University of Saskatchewan
4400 4th Avenue #100S4T 0H8ReginaSKCanada

Zenath Athuman
University of Saskatchewan
4400 4th Avenue #100S4T 0H8ReginaSKCanada

Joram Buza
University of Saskatchewan
4400 4th Avenue #100S4T 0H8ReginaSKCanada

Open Access BMC Research Notes
10.1186/s13104-015-1776-6Petrucka et al. BMC Res Notes (2015) 8:773 RESEARCH ARTICLE Maternal, newborn and child health needs, opportunities and preferred futures in Arusha and Ngorongoro: hearing women's voices This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. *Correspondence: firstname.lastname@example.com Full list of author information is available at the end of the article Page 2 of 10 Petrucka et al. BMC Res Notes (2015) 8:773TanzaniaMNC healthCommunity dialoguesArushaNgorongoro Conservation AuthorityBaseline assessment
Background: With the approaching sunset on the Millennium Development Goals (MDGs), Tanzania continues with its final national push towards achievement of MDG #4 and MDG #5. The Mama Kwanza Socio-economic Health Initiative (MKSHI) was introduced in the hope of contributing to improving maternal, newborn, and child health in Arusha and Ngorongoro. The MKSHI project is a holistic, inter-sectoral approach to maternal, newborn, and child health which aligns with the Government of Tanzania's Vision 2025. At the project onset, a baseline assessment was conducted to launch ongoing benchmarking, monitoring, and evaluation of the project's impacts and implications. The aim of this baseline assessment was twofold. First it was to determine the state of maternal, newborn, and child health in the two project sites. Second it was to ensure that a baseline of key indicators was established as well as identification of unique indicators relevant to the populations of interest.Results:The baseline study was a mixed methods approach to identify maternal, newborn, and child risk factors and indicators in the two target sites. This paper focuses on the qualitative methods and findings. The qualitative component included a series of five community dialogue meetings and thirty-seven individual/dyad interviews with women, providers, and stakeholders. Initially, community meetings were held as open dialogues on maternal, newborn, and child health issues, opportunities, and preferred futures. Individual/dyad interviews were held with women, providers, and stakeholders who held unique information or experiences. Both community dialogue and interview data was analysed for themes and guiding or critical comments. Three over-arching findings emerged: What took you so long to come? How do we know what you know? and How will it change for our daughters?Conclusions: Participant voices are vital in ensuring the achievement of local and global efforts and preferred futures for maternal, newborn, and child health services. This study contributes to the inclusion of women in all aspects of the planning, implementation, and delivery of maternal, newborn, and child health services in the target areas and beyond.

Background

Globally, women and children continue to die of preventable and/or treatable causes which require simple, proven, low-cost interventions [1]. The following list reflects a number of these issues: one in ten hunger related deaths are due to disasters (i.e. drought, floods) with the remainder due to systemic, chronic, or recurring situations; one in eight people globally are suffering from chronic undernutrition with 98 % of these located in developing countries; one in six babies are low birth weight due to prenatal malnutrition; one in four people in Africa is hungry; one in three people in developing countries are deficient in vitamins and minerals; and one in two child deaths are related to nutritional status (~5 million annually) [2][3][4].

Diseases, such as pneumonia, diarrhea, and malaria, account for over 40 % of deaths in children under 5 years of age [5]. Globally, diarrhea is the second most common killer in this age group [6]. Third on the list of causes is malnutrition/undernutrition, including micronutrient deficiencies, which contribute to an estimated 30 % of deaths, despite optimal feeding guidelines, such as the Global Strategy for Infant and Young Child Feeding [7]. In sub-Saharan Africa, the number of underweight children is expected to exceed 43 million in 2015, with significantly more females experiencing Vitamin A deficiency and stunting, which impact on health, educational, and economic futures [8]. Exclusive breastfeeding alone within the first 6 months of life would save about 1/3 of a million children each year worldwide, yet only 30 % of infants in sub-Saharan Africa are exclusively breastfed [9].

Within the struggle to achieve maternal, newborn and child health (MNCH) the Mama Kwanza Socio-economic Health Initiative (MKSHI) was conceived. The MKSHI project, which grew from a long term relationship between Tanzanian and Canadian partners, expands services across sectors for MNCH in select communities in Tanzania. The project aims at demonstrating and informing future models for innovative, quality, and sustainable programs for most vulnerable populations in the Arusha and Ngorongoro Districts. The MKSHI focuses on a social determinants approach dedicated to addressing Millennium Development Goals (MDGs) #4 and #5 for most vulnerable women and children in Arusha (an urban/peri-urban catchment) and Ngorongoro (remote) Districts, Tanzania. In Tanzania, these two specific maternal newborn and child health (MNCH) goals have remained a challenge. As of 2013, Tanzania's infant mortality rates (IMR), neonatal mortality (NM) and maternal mortality rates (MMR) remain high at 38 per live birth, 21 per 1000 live births (i.e., over 48,000 per year/17,000 as first day deaths), and 460 per 100,000 (i.e., approximately 8500 deaths) respectively [10]. Three critical elements considered within the MKSHI are skilled birth attendance, family planning, and post-natal care.

Currently in Tanzania, about half of women are unable to access skilled birth attendance (49 %); family planning (48 %); and post natal care (31 %) [11]. Countdown to 2015 [10] noted that these inequities are embedded in poverty issues with the poorest quintile having attended births 31 % of the time versus 90 % attendance for the wealthiest quintile. As the Government of Tanzania's Vision 2025 [12], the health sector strategic plan III [13], and other health, social services, and strategic national agendas have articulated these realities, the MKSHI project has embedded these into its planning and programming.

This paper reports on the method, results, and learnings from the baseline assessment in Arusha and Ngorongoro, Tanzania. Primarily the intent was to determine the state of maternal, newborn, and child health in the two project sites. Secondly it was to ensure that a baseline of key indicators was established as well as identification of unique indicators relevant to the populations of interest to be tracked and impacted upon during the MKSHI.

Methods

Our selection of a method was based on the goal of being able to 'validate' that the women/communities with whom we were working either mirrored or differed from those represented in government documents-specifically The Tanzanian Atlas of Maternal Health, Child Health and Nutrition [14]. We also sought baseline information on select indicators to enable ongoing assessment of the MKSHI impacts on the women/communities over the course of the project.

Ethics approval was obtained from the University of Saskatchewan Research Ethics Board (BEH 11-328) and affirmed through the Nelson Mandela Institute of Science and Technology. Each tool was pilot tested or expert reviewed. The community dialogue guide, and client interview were piloted at a partnering site as it was felt that this site had a highly diverse population (i.e., illiteracy, poverty, and ethnicities). The health provider and stakeholder interview guides were expert reviewed by members of the project team.

Adjustments to the draft tools were made based on these feedback experiences resulting in a Community Dialogue guide and three separate interview guides (for clients, health providers, and stakeholders).

Sampling

The qualitative sampling was situational and maximized representation as well as identified unique informants and extreme cases.

For the community dialogue meetings, women were recruited by open invitation (using word of mouth and posted messages) in a convenience sampling approach. Women were asked to notify the local clinic at least 2 days prior to the intended session in order to allow planning for seating and refreshments. The clinics were asked to limit the number of women to 25 participants with assurance that if that number was exceeded we would offer subsequent dialogue meetings. It was agreed that we would not hold more than two sessions per site due to time limits on completion, and likelihood of saturation. The participation by community is shown in Table 1. In no situations was a second session held; however, in two communities in Ngorongoro, more than 25 women attended the sessions and the decision was made on the ground to proceed. A group consent process was facilitated by the local leader at all sessions.

For the client interviews sampling was based on identification of individuals from each community dialogue meeting (by the research team) who had unique or specific contributions that required further exploration. From there, a snowballing process linked us to other individuals in their communities (who may or may not have participated in the community dialogue session) (see Table 2). All interviewees were provided with a consent form in Swahili and given a verbal explanation by a local staff (i.e., interpreter) employed by the MKSHI clinic. Voluntary consent was given either in writing or verbally by the interviewee.

Data collection and entry

Data collection and entry was guided by the following principles of:

Using local language (which meant local data collectors). Ensuring real-time or near real-time capture and entry (to minimize loss of ideas or insights). Considering respectful and relevant data capture procedures (to avoid unnecessary time and information).

Three steps were followed in this baseline assessment.

Step one: training of community researchers Three community health workers were trained-one for the Arusha District and two for the Ngorongoro District. The workers received a 12 h training session on community based research and the specific tools for this project. These individuals participated in the pilot testing exercise at Mrombo in order to both experience the process and to contribute to the revision of the tools. They were not involved in the health provider or stakeholder interviews.

The fieldwork included logistical preparations as well as data collection and entry efforts. The entire group participated in the first site (Philips) in order to model consistency and give the opportunity for any questions or methodological adjustments. The team was then split with one group continuing in Arusha and the other beginning their fieldwork in Ngorongoro.

Data entry was done by the onsite research group. Teams would conduct data collection on Mondays, Wednesdays, and, if necessary, Fridays, with data entry occurring on alternate days.

Step three: validation/quality monitoring Although listed independently and sequentially, there were constant efforts to compare and contrast the findings across sites and tools. The quality monitoring of the data was important to ensure all data elements were being captured, and correctly reflected. The team attempted to have weekly meetings to share their experiences, but the amount of fieldwork overwhelmed them and only one meeting occurred at week 2. Hence, final data integrity reviews was left with the lead research team.

Results and discussion

Overview

Through community dialogues and interviews with select women, the research team heard a range of personal stories, anecdotal recollections, and reflective thoughts on  the state of maternal, newborn, and child health care, programs/services, and providers. The community dialogues included 132 women in five communities ranging from urban to peri-urban to remote locations. During these sessions, the focus was on perceptions, experiences, and preferred futures of MNCH. In addition, ten women were recruited to provide brief interviews. Six individuals identified from the community dialogue groups were selected as:

Two individuals requested an interview as they had a story/experience they did not wish to share in the group.

Three individuals shared a story or issue that was flagged by the team as unique and meriting further exploration.

One individual was a non-health professional who had insights that the team felt could contribute to an added dimension.

Following individual interviews, the participants were asked if they wished to recommend someone else from their community who might have additional insights or perspectives on MNCH. Although six recommendations were received only four agreed to participate. Because these women constituted a small number of participants, and due to the nature of their stories, we choose not to locate or name them in order to protect their identities.

Although we intended to use the same instrument as the community dialogues, the original core group of women wanted to focus on experiences and it was decided that this should be the focus of the individual interviews for all cases.

Perceptions of MNCH

The women were asked about their perceptions or thoughts about quality of MNCH services, and providers. In inviting them to this discussion, they were told that we were most interested in their personal and community viewpoints. The participants are recognized by abbreviations of their names and which district they are associated with. Their responses, across all sites, fell into two major categories-maternal and child issues and gender influences. Within each of these categories a number of themes and/or sub-themes were identified and will be discussed herein.

Perceptions of maternal and child issues-what we heard

The women stated that MNCH was perhaps the most difficult aspect of their lives. Whether the challenges were about risks, finances, or physical aspects, the women spoke clearly about what type of services they might have to help them "live through this time" (CC Arusha).

it (pregnancy) should be a happy time, but for us there is fear and worry about how things will go or not. Maybe we have had a sister die or lost a child before, so we know the risks. So how can this be happy? (N. Arusha).

women have lived and died bringing children to this world…but when it is your turn you cannot help but be a bit afraid how you will make out. (L. Ngorongoro).

Women in the Arusha District spoke about the perception that the woman has to take charge and know as much as she can about MNCH. They spoke of knowing the difference between a fever and malaria or when it is time to take their child for care. There was a sense of pride and also a sense of necessity in their discussion of this topic. They felt that "if we not know who else would care like a mother?" (B. Arusha). The emphasis was on the imperative of a mother being aware of the health care needs and services in order to access these in a timely manner if needed.

Many women perceived that there is no one to help them. Some spoke of their absent husbands who provide minimal support or presence throughout the pregnancy, delivery, and child-rearing. The attitude of "they are just men" (D. Ngorongoro) was consistent across sites. Further, the lack of health providers and health facilities was cited as further evidence that "we are more alone" (M. Ngorongoro).

Through thematic analysis, three themes were extracted in relation to perceptions of MNCH-it's about survival; knowing as a mother should; and we are on our own.

Perceptions of gender influences-what we heard

The women told us that MNCH is a women's issue and that very few men would see it any other way. Most of the women spoke of not expecting to have their husbands by their side during labour and delivery. Women even spoke about being "left at the clinic when the time comes" (B. Arusha).

He will not care about even coming to the ante-natal clinic, so I go without him. It is just the way it is and nothing can change that. So I walk the 3 km with others from the village who are too pregnant. (L. Ngorongoro).

The issue of decision making and who decides on health care issues was discussed. At times there were extremes of emotion (both agreement and disagreement) on this issue. Most agreed that men held the ultimate or final decision in matters of money and most resources.

This was seen as impacting on the type of care that might be possible. A general consensus was heard on the shifting of this power, especially in the Arusha District. The women spoke of "if only I had the shillings in my pocket" (A. Arusha) or "when it is my money" (R2 Ngorongoro), clearly indicating a gender difference in control of financial resources, which is, at times, vital for accessing MNCH. With respect to perceptions of gender influences, two themes emerged-women present/men absent and women do/men decide; as well as one minor subtheme emerged which was attached to the second major theme-lack of resources equals lack of access.
I

Experiences of MNCH

The women shared their experiences and stories regarding MNCH services and providers. The responses, across all sites from the community dialogues, fell into three major categories-experiences of care, roles/responsibilities, and family planning.

Experiences of care-what we heard

Of all the discussions, this topic had the most input and was highly animated. The women were passionate about their care needs, explicit about their care experiences, and concerned about care quality. With a seemingly singular voice they all indicated a need for more MNCH care-and, more importantly, quality, local MNCH care. The women told of distances traveled, lack of health providers, lack of supplies, and mistreatment by health providers (i.e., rudeness, yelling).

to go for care so many times before and after the baby comes… but sometimes they are so busy that we just wait and wait only to leave not seen. (R2 Ngorongoro).

At dispensaries and even health centers don't have doctors and so few nurses…we go for care and find they don't have staff or supplies. So I don't know if it is safe? I went to get my baby immunized and was told the government had run out of the medicines and no one knew when we would get the new medicines. So now I worry that my baby will get sick. (P. Arusha).

Two major themes arose with respect to experiences of care-not just more but better care and so little for so many. There was one sub-theme related to the first major theme which was do as you are told.

These findings were mirrored in the individual interviews. Three of the women from the community dialogues and one from the snowballing capture focused on medical stories. In these instances, the women spoke about issues of malpractice, negligence, and systemic flaws. Three of the women's stories related to care issues that spoke to professional misconduct and failure to provide for care. One of the women spoke of how she came for services because she was concerned that she felt her baby was not moving as much. The staff at the clinic criticized her for wasting their time and sent her back home nearly 17 km. Within 3 days she was experiencing a high fever and foul discharge. By the end of the ordeal she not only lost her unborn child, but would never again be able to conceive. Another told of watching her sister hemorrhage to death after delivery because there were 7 other active deliveries and only one midwife and two nurses. The lack of staff and, in her opinion, their exhausted state led to the death of an only sister, new mother, and young wife. The third woman talked about her experiences due to female circumcision. She had begged for a caesarian section, but instead experienced severe tearing which took months to heal and have left her unable to have comfortable sexual experiences. Her concern was for other women who have been traumatized in this way and a plea that someone work on reducing this risk. The final woman told the team about the differences in care received by women based not on need but on financial resources. As a social worker she struggles to see the poor and less educated treated at the lowest level facilities, often with the lowest educated staff. Yet, it is these women who require additional resources, supports, and treatments.

Two additional major themes were extracted respecting experience of medical care-failing to provide care and failing to care.

Experiences of roles and responsibilities-what we heard

Although there was some obvious overlap with the perceptions findings (especially related to gender), this category emerged strongly. The women shared their lived experiences of multiple roles, responsibilities, and expectations which makes taking care of their personal and children's health very challenging. There were com-ments about how culture affects these roles and responsibilities and makes change seem impossible. Sometimes the cultural ideas about MNCH conflict with the health system. For example, the Maasai women described that half rations are provided to the pregnant woman with the intention of reducing the birth weight of the baby theoretically causing less difficulties in labor.

we are responsible for everything…the home, water, children, everything even the parents…and then we have to worry about the coming baby. It is too much. (S. Ngorongoro).

Two major themes were derived in relation to experiences of roles and responsibilities-responsible for everything and everyone and MNCH as cultural.

Two of the women from the community dialogues and two from the snowballing capture participating in the interviews focused on social stories. The women spoke about issues of family violence, poverty, and family interference. Their stories not only enriched the understanding of gender and cultural elements that had been previously shared, but focused on the outcomes of these elements.

Two women told of the near daily assaults and violence perpetuated on them throughout their pregnancy and their fears of dying. They told us that there were no resources for such family violence and the issues were very real for many women. It was almost implied that this was the norm in some groups. One woman spoke of how poverty had cost her three children. She told us how each child could have lived with medicine or proper food, but the children were not valued. Her story was filled with a plea for programs to help women like her have healthy babies. She spoke of feeling "less a woman" in the eyes of society because she could not have healthy children. The final woman in this group spoke about the family pressures of Tanzanians where it is expected to have many children and even many wives.

She said that many woman keep having babies at risk to their own lives and their babies' lives just because it is expected. She said some husbands will even leave or marry another wife if they feel you are not productive enough.

Three additional major themes were extracted respecting experiences of roles and responsibilities-it's a violent time; further marginalized; and when family values don't value.

Experiences of family planning-what we heard A number of women talked about family planning and choices. This topic included many side conversations and even debate more than dialogue. Some were very open that they used family planning methods; others spoke of "(getting) the needle without him (my husband) knowing" (O.

Arusha). For those in favor of family planning, they spoke about how they believed their lives and their children's lives would be better. There were discussions about the cultural (i.e., "children bring wealth to my husband", S. Ngorongoro) and religious (K. Arusha) aspects of family planning. There was limited talk about using birth control to have more time (birth spacing) between pregnancies, but most women talked about no more children. All of the women stated that their husbands would not take the lead in family planning so it was up to them to decide.

After my last child the midwife asked me about family planning. She went to my church, so I asked her but God does not want this. She tells me God wants healthy children and their mommies. I think she is rights, so I take the needles now. (R. Arusha).

In terms of experiences of family planning, two major themes were extracted-making the cover overt (i.e., revealing family planning) and family planning as a means to family progress.

A final aspect of the experience of family planning related to ethical issues in care. In this instance, one woman from each source contributed to the ethical stories. The women spoke about abortion and post-abortion care. We recognize that abortion is not legal in Tanzania, however, that does not mean such procedures are not being conducted often in the most rudimentary of conditions. The women both told of personal or known cases of sought abortions. In both stories, they spoke of how the MNCH system must recognize and address this gap. Women and young girls, according to them, are being forced to risk their lives. They stated that the health care system does not treat women who have had an abortion very well. Both women questioned how ethically the health system could not respond to this need.

One additional major theme was extracted-desperately seeking ethical MNCH care.

Preferred futures for MNCH

The women generally took time to think about what they wanted to see in their future MNCH palette. There were a number of women who described system improvements and this launched a number of discussions about what needed improving, what should come first, and where this should happen.

Preferred futures-what we heard There was agreement on the need for more health providers (especially nurses and midwives), more equipment and supplies (such as gloves), and more facilities. Some women, especially from Ngorongoro, felt there was a need for transportation both to get to appointments and for health emergencies. Where the conversation became very interesting and touching was in one site in Arusha District where the women focused on making a difference in MNCH for the future women. It was a passionate plea to make changes now so that women and babies would not die.

I don't think I am any better off for (MNCH) care than my mother was…really I think we stayed the same or maybe even are worse. I don't know if this can be fixed but I want to see it better for my children and grandchildren. Women need to work together for that. (S. Arusha).

Two major themes were extracted from this aspect of the community dialogues-envisioning a resource filled future and for our daughters.

Reflection on findings Thematic summary

A brief review of the themes is highlighted in Table 3. Although frequency counts are reported these should not be interpreted as priorities or levels of importance. Rather, the intent was to show an overall distribution of responses across topic and themes.

Situating the findings

Many study findings align with the existing literature related to MNCH globally and in sub-Saharan Africa.

More than 1000 women die each day during pregnancy and child birth mainly due to poor access to effective interventions [15] which resonates with the perceptions and fears expressed by the participants in this study. In terms of the MDG #4 and #5, it was important to recognize that these participants continue to be 'left behind' in terms of both child and maternal health care and status.

The participants in this study indicated that access to health care and appropriately trained providers is imperative and more notably in their absence the consequences are grave. This is reflected in the work of the African Union [16], which found that African women and children continue to die from three key delays: seeking care, reaching the health facility, and receiving appropriate care by health providers. Again, these are issues and contributing factors which have contributed to the failure of Tanzania's health system to fully realize the MDG #4 and #5 goals.

In the present study, the role of gender as impacting MNCH outcomes, which is reflected in the literature respecting how social and cultural beliefs are fundamental to the engagement of men in the health of women and children [17]. Globally, gender inequality is one of the most important drivers of poor health and wellbeing outcomes for women and their children [18]. The emphasis is on the need for MNCH interventions aimed at active roles of men in improving and supporting MNCH [19,20]. Although many authors [21,22] speak of the primary and essential role of nurse and midwives in the care of laboring women. However, the literature is replete with description of poorly remunerated staff [23,24], lack of equipment and supplies [25], and high workloads [23,26]. These conditions amongst others have contributed to an alienated and demoralized workforce-no longer able to care and often leading to abuse in the patient-nurse relationship ranging from physical to emotional to verbal attacks [27,28]. Mbabazi [29] reports a number of negative labour experiences which sound ominously similar to those reported by participants in the current study.

A number of study participants spoke of the need for safe abortion care in Tanzania. Globally, there are over 75 million unintended pregnancies which contribute to about 22 million unsafe abortions [26]. The challenge lies in the unmet need for contraceptives, most often in developing countries [26]. Although nearly one-third of maternal deaths are related to unsafe abortion, only 5 % of health facilities in Tanzania provide post abortion care [15].

As the participants envisioned the future of MNCH as a well resource health system which is highly responsive. According to Mwaikambo [30], there is a need to address two critical aspect of MNCH-health system factors and non-health system factors. Within health system factors, the emphasis lies with improved health infrastructure, increased skilled human resources, access to modern family planning, and appropriate equipment and supplies, plus a strengthening of policies to embed socio-cultural and gender based strategies [30]. In terms of non-health system factors, increased community engagement in MNCH program development and delivery, redress of inequalities, and informed health seeking behaviors [30].

Study limitations

The findings of the study are limited by the cross sectional and geographical limitations of the research. There was no opportunity to return to the communities to validate the themes, which would strengthen the credibility and trustworthiness aspects of the study. The translation from local languages to English was reliant upon the capacities of the local research team members, so there may be some limitations and incongruencies in this aspect of the work.

Implications of findings

The findings of this study reached beyond the statistical and often objective reporting of the mainstream government documents (i.e., cited above). This study put a story to the experience and personal insights into the situation which lacks in the traditional policy documents. The study situates MNCH not in the statistics, but in the lived experiences of many of the women and their communities. It calls for programs which not only change the care environment, but the cultural understandings of MNCH. It highlights the disconnect of programming from the reality of the women especially in areas of gender and culture. It challenges the behaviors of care providers and decision makers on professional and ethical matters. The findings are foundational for future replication research in other areas of Tanzania. In addition, it challenges researchers to undertake studies which consider cultural and gender aspect in MNCH in Tanzania. Another key area for future research is the quality of care and care provider-patient relationship which was a recurring issue in the data.

Conclusion

This study engaged the community through a series of community dialogues and interviews on outlining a preferred future for MNCH. Through these two approaches, we accessed 132 community participants in the dialogues and ten female clients in the interviews. It was evident from the various sources that health services alone would not determine the successes and achieve the necessary changes for MNCH. Rather the complexities of social, economic, gender, cultural, and political interactions were collectively seen as critical determinants. We also heard that the challenges ranged from simple to complex; from individual to community; as well as from adolescence to end of child-bearing ages. Lack and/or inequitable distribution of resources and minimal control of resources by the target group of women were seen as a significant impediments to progressive and responsive MNCH.

The visions for MNCH were likely the most inspiring and overwhelming contributions to the baseline assessment. Across the spectrum of informants we heard about a future with well-resourced MNCH facilities properly staffed and operated. We heard about the preferred future of ethical, safe, barrier free, and patient-centered MNCH. Over one-quarter of the comments related to issues in MNCH, with nearly another one-quarter relating to experiences (or examples) of the MNCH care continuum. The 45 themes/subthemes were reconsidered and yielded a series of lessons learned. Three main lessons learned were 'take aways' from the words of the women we heard.

What took you so long to come?

Many of the issues and concerns revealed in the baseline assessment are longstanding and have remained unaddressed. As a result we realized that there is no simple fix or answer to issues that have huge social, economic, cultural, and historical roots. Throughout the baseline assessment evidence of poor care quality, underservicing, and questionable capacities was seen. Hence, this lesson is critical as we move forward with regards to the change processes and potential barriers to realizing the MKSHI goals. However, the corollary lesson learned was that there was hope that this time might result in making things better for the women and children. The participants remained optimistic that their right to safe and quality MNCH would come with time and effort. This is an important insight for MNCH programs generally that the solutions must be inter-sectorally based and embedded in an understanding of change.

How do we know what you know?

The MNCH environment is dynamic and filled with evidence for practice. Patients both indicated a desire to be more knowledgeable and use knowledge more effectively to have better outcomes. Through the qualitative (and quantitative which will be reported in a future article) components of the baseline assessment we gained more evidence of the inequities of knowledge distribution. The lesson learned is that we cannot assume that the knowledge is either 'out there' or understood. At times there is a lack of information, whereas at other times there is an overload. Within an ethical MNCH system there was a sense that the best information, the best practices, the best equipment, and the best trained providers would be possible. The sharing of knowledge and the achievement of knowledgeable users of the MNCH systems is a goal that goes far beyond this project and should be high on the agendas of health providers, researchers, and policy makers.

How will it change for our daughters?

The third lesson learned came from a passionate plea for a better future. The lesson learned was that there is a future vision for MNCH. It was as if the baseline assessment captured this vision, laid the start of the path to the future, and, more importantly, created a sense of responsibility for making the difference for the daughters and granddaughters. The awareness of all participants of the issues, challenges and deficits did not take away from their intention and dream to see positive changes in MNCH. The connection of women through generations and gender creates a solid foundation for MNCH programs.

This final lesson was felt strongly as the most revealing and powerful as it emanated from the women themselves who were envisioning better MNCH programs and services not for themselves but FOR THEIR DAUGHTERS. In this they were heard!

Table 1
1Sampling for community dialogue meetingsSite
Number of attendees

Philips
17

Mrombo
14

Olbalbal
47

Misygio
21

Alilayli
33

Total
132

Table 2
2Sampling for individual interviews for womenSite
Number of interviewees

Philips
3 (2 Participants; 1 non participant)

Mrombo
1 (1 Participant)

Olbalbal
3 (1 Participants; 2 non participants)

Misygio
1 (1 Participants)

Alilayli
2 (1 Participants; 1 non participants)

Total

needed to go to the (private) hospital, but my husband said no go to the (government hospital) instead. They did not have the working ultrasound, so we came back home. I did not have the test and now my baby is very sick all the time. (A. Arusha). My husband knows that I need money every month to check the baby for growing and weighing. He does not question me but gives it so that I can take him. I think he has learned that this is good for our child. " (P. Arusha).

Table 3
3Qualitative theme frequenciesTopic
Themes/subthemes
Frequency
Total

Perceptions
It's about survival
14
57 (28.4 %)

Knowing as a mother should
10

We are on our own
9

Women present/men absent
10

Women do/men decide
8

Lack of resources = lack of access
3

Experiences
Not just more but better care
38
97 (48.2 %)

Do as you are told
9

So little for so many
15

MNCH as cultural
13

Responsible for everything and everyone
6

Making the covert overt/revealing family planning
12

Family planning as family progress
4

Preferred futures
Envisioning a resource filled future
7
11 (5.5 %)

For our daughters
4

Socially speaking
It's a violent time
6
12 (6 %)

Further marginalized
4

When family values don't value
2

Medically speaking
Failing to provide care
12
17 (8.4 %)

Failing to care
5

Ethically speaking
Desperately seeking ethical MNCH care
7
7 (3.5 %)

201

AbbreviationsIMR: infant mortality rate; MDG: Millennium Development Goal; MKSHI: Mama Kwanza Socio-economic Health Initiative; MMR: maternal mortality rate; MNCH: maternal newborn child health; NMR: neonatal mortality rate.AcknowledgementsThe authors acknowledge the contributions of the Canadian Department of Foreign Affairs, Trade and Development as the primary funder of the MKSHI. The authors acknowledge the contributions and openness of the participants and the facilitation offered through the Pastoralist Committee in Ngorongoro Conservation Area.Authors' contributions PMP designed the study and protocol, led the data analysis of the qualitative component of the baseline assessment, and wrote the first draft of this manuscript. SLB contributed to the original study design and protocol. MDL contributed to the project conceptualization. CSG co-managed the data analysis of the study. ZA and JB contributed to the original study design and protocol and supervised students involved in components of local data collection. All authors read and approved the final manuscript.Author details 1 University of Saskatchewan, 4400 4th Avenue #100, Regina, SK S4T 0H8, Canada. 2 Mama Kwanza Socio-economic Health Initiative, Arusha, Tanzania.3Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania.Competing interestsAuthors have declare that no competing interests exist. Submit your next manuscript to BioMed Central and we will help you at every step:
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BMC Medical Education A virtual computer lab for distance biomedical technology education

Craig Locatis email@example.com
Office of High Performance Computing and Communications
National Library of Medicine
BethesdaMarylandUSA

Anibal Vega firstname.lastname@example.com
Center for Information Architecture in Research
University of Puerto Rico Medical Campus
San Juan, Puerto RicoUSA

Medha Bhagwat firstname.lastname@example.com
National Center for Biotechnology Information
The National Library of Medicine's National Center for Biotechnology Information
National Library of Medicine
BethesdaMarylandUSA

Wei-Li Liu email@example.com
Office of High Performance Computing and Communications
National Library of Medicine
BethesdaMarylandUSA

Jose Conde firstname.lastname@example.com
Center for Information Architecture in Research
University of Puerto Rico Medical Campus
San Juan, Puerto RicoUSA

BMC Medical Education A virtual computer lab for distance biomedical technology education
10.1186/1472-6920-8-12BioMed Central Page 1 of 8 (page number not for citation purposes) Research article * Corresponding author
Background: offers mini-courses which entail applying concepts in biochemistry and genetics to search genomics databases and other information sources. They are highly interactive and involve use of 3D molecular visualization software that can be computationally taxing.Methods:Methods were devised to offer the courses at a distance so as to provide as much functionality of a computer lab as possible, the venue where they are normally taught. The methods, which can be employed with varied videoconferencing technology and desktop sharing software, were used to deliver mini-courses at a distance in pilot applications where students could see demonstrations by the instructor and the instructor could observe and interact with students working at their remote desktops.Results: Student ratings of the learning experience and comments to open ended questions were similar to those when the courses are offered face to face. The real time interaction and the instructor's ability to access student desktops from a distance in order to provide individual assistance and feedback were considered invaluable.Conclusion:The technologies and methods mimic much of the functionality of computer labs and may be usefully applied in any context where content changes frequently, training needs to be offered on complex computer applications at a distance in real time, and where it is necessary for the instructor to monitor students as they work.

Background

There is a high demand for training in the use of databases supporting resources developed by the National Center for Biotechnology Information (NCBI) [1]. Usually, instructors have to travel to distant sites, or students have to come to the National Library of Medicine (NLM) for this training. It is not always possible for instructors to visit all sites where training is needed, especially if located in other countries. Conversely, travel to NLM can be expensive and inconvenient, particularly for trainees in doctoral or post doctoral programs. Consequently, the application of distant education technologies is an attractive supplement to face to face approaches. Technologies using Internet protocols (IP) are exceptionally useful because the information resources themselves are Internet accessible. In addition, the Internet provides a range of synchronous and asynchronous communication services that can be employed for distant education such as email, the Web, messaging, video streaming (live and on demand), and two way interactive videoconferencing. Given the nature and complexity of the resources taught, it was highly desirable to have the same real time interaction with students at a distance that occurs when teaching is done in person. The Internet has made it possible to offer more education online and at a distance. This e-learning has taken many forms as the capacity and character of the Internet has changed. The earliest e-learning involved use of email to send information and exercises to students, but soon evolved to using the Web, message boards and streaming video as these additional services came online. Internet protocols are currently robust enough for two way point to point and multipoint videoconferencing, especially over advanced research and education networks such as Internet2 and, to a lesser extent, over the commodity Internet. Although students appreciate the convenience of time and place flexibility asynchronous communication affords in distance education, they prefer classroom instruction and face to face interaction with teachers and peers [2][3][4]. Consequently, many institutions have adopted blended learning approaches combining face to face and distance learning [5]. Videoconferencing is becoming part of the mix of technologies to provide distance education and blended learning in varied areas of health science [6][7][8][9].

Transactional distance, the physical separation that increases the likelihood of miscommunication and misunderstanding in distant education, is a function of teacher-student and student-student interaction [10][11][12]. Videoconferencing can reduce this distance because it accommodates much of the immediate and non-verbal communication characterizing interaction that is face to face [9,12]. The extent to which synchronous communication via videoconference can substitute for interaction in person is unclear [13,14], but there is evidence that when video is used for teaching, providing bi-directional interaction produces better learning outcomes than when communication is just one way [15] and that student satisfaction levels are higher in distance learning programs when the channel of communication is video versus text [4]. The technology has the potential of extending sense of presence and sense of community, factors having positive affects on student attitudes toward distance learning [16][17][18]. There is evidence, however, that students at the site where conferences originate interact more than those at distant sites and that instructors concentrate more on students that are physically present [19]. The technology can constrain dialog [16,19] and students at distant sites often feel more disconnected than those at originating ones [17,20]. This detachment can be mitigated when students are not physically present at the origination site so the instructor can concentrate fully on those at a distance [21].

While the ability to see and hear each other and interact in real time is invaluable in a videoconference, a concomitant problem in education involves sharing resources. There not only is a need to engage in conversation, but also to share slides, browsers, and other software to convey information, provide practice, and give feedback and assistance. The ability of teachers and students to interact with the same desktop applications in real time may extend sense of presence and reduce transactional distance by adding a "hands on" dimension to the audio and video communication channels the technology affords.

Since computer applications can be complex and highly interactive, instruction on their use frequently occurs in computer labs. The labs have numerous pedagogical advantages, allowing students to interact instantly with each other and their instructors, have immediate hands on experience performing tasks instructors demonstrate, and complete exercises in which they apply what they have learned to solve more complex problems while the instructor is present to help. Since many of these lab problems, such as formulating and conducting a search, might be solved appropriately in many different ways, it is not always possible to provide pre-packaged feedback about how the problem may be solved or to anticipate and control for varied difficulties students may encounter, an approach common in much asynchronous online education. This problem is compounded in biotechnology because online databases and information sources change continually. The content is constantly updated and features are often added or modified that alter the interface. When instruction is synchronous, it is possible to teach the most up to date version of the application without having to revise online training materials. It is also possible to immediately address variations in retrieval when students employ different search strategies or features of the interface. Instructors can monitor student progress, answer questions, and resolve problems immediately in the laboratory setting. They can walk around the lab, observe students' desktops, and, if the lab is equipped with appropriate switching devices, project any given student's desktop to address issues of interest to the entire class.

NCBI offers several 2.5 hour format mini-courses [22] at the National Institutes of Health and at locations around the country to over 4000 students a year. The courses use a paired problems approach in which the first of two sim-ilar problems or problem sets is solved by the instructor during the first hour on a computer linked to a projection system, while the students watch; in the second hour, the students tackle the second paired problem, or set of problems at their own computers, as instructors help the students when needed. These courses have been effective as practical introductions to bioinformatics procedures. The challenge faced in developing the virtual computer lab was how to replicate the desirable features of face to face interaction in actual computer laboratories when education is provided at a distance. Videoconferencing accommodates much of real time interaction and has been implemented at NLM. But there is the additional requirement that faculty and students also share computer applications. Using the Internet to share slides or a web browser on an instructor's desktop with many different students at a distance is routine, but allowing the instructor access to all the distant student desktops to provide assistance in a manner typically done in computer labs is more difficult. Methods were devised to combine bi-directional video and desktop application sharing software to realize some of the benefits of face to face instruction in computer labs at a distance.

Method

Sharing applications in one direction, from the teacher to the students, can be accomplished several ways. The most widely used technologies for videoconferencing over IP comply with the H.323 standard. This standard embraces several sub-standards for compressing and decompressing video, initiating calls, and sharing data and applications. The H.239 sub-standard has recently been added to its earlier T.120 sub-standard for incorporating desktop applications into a conference. H.239 is used most often with standalone videoconferencing appliances and allows an end point to connect a desktop or laptop to the videoconferencing device so that data from the computer can become part of the video stream. The data consumes most of the screen space and displays at a higher resolution, while video of the presenter can appear in a small window (picture in picture). Prior to implementation of H.239, the data would be displayed as standard NTSC television, without picture in picture capability, and the resolution was often inadequate, especially if presenters wanted to show web pages and other information with smaller text.

H.239 is useful when a single end point (e.g., that of the instructor) needs to display information simultaneously to one or more other end points (e.g., those of the students), but it is insufficient for accommodating sharing from all participants. If an instructor wanted to access the desktops of students at a distant site, each of the student machines would have to be connected to a H.239 device or have H.239 software installed. In addition, the students would need to be familiar enough with its operation to inject display of their desktops into the conference at the appropriate time. Moreover, a multipoint conferencing unit (MCU) is needed that is robust enough to accommodate desktop streams from all participating end points. The MCU and extra individual devices or software add expense. Finally, since end points having older H.323 technology are not able to accommodate the H.239 capability that has been added to the standard, only sites having the latest technology can participate.

The T.120 standard also is used in H.323 videoconferencing products, especially those that can be installed directly on computers. It allows any end point in a conference to share one or more of its applications or its entire desktop with other computers and, optionally, give others control. T.120 functionality is useful, but all participating end points have to initiate sharing with the H.323 videoconferencing software and allow outside control. While an instructor familiar with the product might do this easily to share their presentation, it presumes students are equally familiar with the program to perform the same tasks when they need to show their desktops to receive assistance. In addition, it can add expense if copies of the usually proprietary H.323 software have to be installed on each student machine. Finally, there are technologies for videoconferencing over IP in widespread use that are not based on the H.323 standard and that may lack the functionality of T.120 or H.239.

Video delivered over IP is bandwidth intensive. It consists of a series of individual pictures or frames that are displayed at a rate of thirty per second to create the illusion of smooth motion. This data has to be digitally encoded, transmitted, decoded, and redisplayed at participating sites. Mechanisms for compressing and decompressing video (codecs) are employed to keep the video streams manageable. Videoconferencing technologies can use any number of codecs and the approach to application sharing employed in the virtual computer lab does not rely on using a given codec or videoconferencing approach. This is accomplished by separating application sharing and videoconferencing. Additional software is used that solely performs the application sharing tasks through a second IP connection and that operates concurrently with the videoconferencing program. The students and instructor constantly view each other on the videoconferencing display and the applications they use are seen on a second display. Any commercially available H.323 product (e.g., Polycom, Life Size, or Tandberg), open source program (e.g., Access Grid or Conference XP), or other IP videoconferencing technology can be used to transmit audio and video.

Separating the transmission of audio and video from the transmission of data also adds flexibility in sharing desk-tops, since there are many desktop sharing software options that can be used. These include relatively recent commercial products, such as Microsoft's LiveMeeting having additional whiteboard, messaging, and other features and Virtual Network Computing (VNC) desktop sharing programs that have been in use for over a decade. The latter are designed especially for sharing applications on remote machines and many of these programs, such as RealVNC and UltraVNC, have versions that can be used for free.

In the virtual computer lab, a VNC server runs on any machine that will share its desktop and the machines that will view the desktops run VNC clients and connect to the servers. A particular VNC product was used in the virtual computing lab biotechnology courses only because it enables the smooth manipulation of a NCBI-developed 3D molecular visualization program, Cn3D [23], allowing users to rotate molecules and to highlight, remove, or add certain elements once a molecule is retrieved from a database (Figures 1 and 2). The 32 bit color depth used by the program causes latencies when molecular models are manipulated over networks. The VNC product employed could change the color depth of the shared desktops to 256 colors, reducing latency with minimal degradation in image quality so the models could be manipulated smoothly at a distance. Any desktop sharing program might be used, however, when applications are less computationally intense.

In the virtual computer lab, the instructor communicates with the students at a remote computing facility by videoconference and uses a second computer running a VNC server to present the slides, web database interfaces, Java applets and molecular visualization software that are part of the biotechnology education. A computer run by an operator at the distant end point uses a VNC client to connect to the instructor's presentation computer. The operator's machine is projected at the remote site so the class can see the applications the instructor demonstrates. In addition, each student computer is set to run a VNC server transparently in the background prior to each training ses-Molecule retrieved from the molecular structure database Figure 1 Molecule retrieved from the molecular structure database. sion. The instructor is able to access the desktops of individual student computers during the hands on sessions that follow demonstrations by using a third computer running a VNC client and preset scripts. The instructor asks the students having problems the name or number of the computer to which they have been assigned and activates the associated script to access and view its desktop. The operator at the remote facility can disconnect from the instructor's machine and run the same preset script to simultaneously access the student desktop and project it (Figures 3 and 4). In this way, the entire class can participate in the review of the problem and the feedback the instructor provides any given student.

Results

Two pilot implementations of the virtual computer lab were highly successful. The first used H.323 videoconferencing for communication between NLM and the University of Puerto Rico Medical Campus. The second used InSORS, a commercial program based on Access Grid

The virtual computer lab connectivity model Figure 3 The virtual computer lab connectivity model. open source videoconferencing, for communication between NLM and the University of Michigan Medical School. The technologies use the same video codecs, but the latter can accommodate simultaneous video streams from multiple cameras. There were no students present at the instructor's site so attention could be devoted entirely to those at a distance in each pilot. In both cases, there were no technical difficulties and the ability to access student desktops proved very beneficial. The instructor could literally diagnose problems the students had at a glance, take control, and fix them.

Eight graduate and post-graduate students from the University of Puerto Rico and seven graduate and post-graduate students from the University of Michigan participated in the two pilot studies and completed the standard evaluation form used for all mini-courses. The form is a five point Likert scale asking students to rate the organization of the lecture and hands on components of the course and the course's usefulness. All the students at the University of Puerto Rico gave the course's organization the highest rating. All ratings but one of the course's usefulness were the highest possible and that rating was second highest. Five of the University of Michigan students gave organization the highest rating and two gave it the second highest. Six rated usefulness highest and one rated it second highest. Overall, the students at both institutions gave the instruction exceptionally high ratings. In addition, students in each pilot had an opportunity to make open ended comments on the evaluation forms. Comments from the students at both schools were highly enthusiastic and the most frequent ones concerned the organization and relevance of the course and the quality of teaching. These evaluation outcomes are similar to those when the course is offered in person, indicating that distance and the technology did not adversely affect how students perceived the learning experience. No data were collected specifically on the two videoconferencing technologies. NLM staff felt both videoconferencing technologies were useful, but that the one used in the second pilot enabling multiple video streams from the remote site provided a better sense of presence, making it easier to see and interact with students.

Discussion

The virtual computer lab was a viable approach to providing training on complex databases using computationally intense 3D molecular visualization software. There was the high degree of real time discussion and desktop sharing approximating the teaching possible when students and teachers are collocated physically in computer labs. The interaction between sites was in real time with little latency, even when using the molecular visualization software, and there were no technical problems. The lack of technical difficulties was probably due in part to the use of late model computers that could accommodate the modeling software and the use of Internet2, a national high performance research and education network, to communicate between end points. Preliminary tests with the University of West Indies in Jamaica indicate that the virtual computer lab model might be enabled on less advance networks if audio and video is transmitted at lower bandwidth.

The virtual computer lab has two major implementation issues. The first is the need to have an operator at the remote computer facility. Someone has to install the client and server software on the remote machines and create the access scripts, which can be automatically generated by the VNC software with a few keystrokes. The operator has to be present during class sessions to access and project instructor and student machines. The second issue is the VNC desktop sharing software that some consider a security risk. The VNC software can be set to allow showing a desktop while blocking external control. This setting does not impact the use of the instructor's machine but it is undesirable for students, since the instructor often has to take control of their desktops, move windows, and change search strategies when providing students feedback. Security can be raised by instituting passwords to access the VNC servers and the passwords can be incorporated into the scripts automating the access process. If necessary, firewall rules can be adjusted to allow outside access to the student machines only from the IP address of the machine the remote instructor is using.

Conclusion

The virtual computer lab works over advanced networks and may work over networks having less capacity and

The virtual computer lab in operation at the instructor's site Figure 4 The virtual computer lab in operation at the instructor's site.

quality of service. The methodology is viable in other contexts where computer applications change frequently, immediate interaction is desired, complex technologies are to be learned, and there is a need to monitor student work in real time. In such situations, the time and money required to develop asynchronous learning materials may not be justified, given the quick silver nature of the content. Moreover, it is difficult to engineer such materials when the skills being taught can be applied in varied ways and there many different routes to solving problems. Real time interaction with experts who can diagnose student difficulties on the fly and provide tailored feedback is advantageous in these circumstances.

Real time interaction has the potential of reducing transactional distance and increasing sense of presence in distance learning. In most distant learning contexts, such interaction has been limited to what is written, said, or sometimes shown. The virtual computer lab extends communication at a distance by enabling teachers to directly observe students working with applications and demonstrate performance when providing feedback, much like they would when seated beside the student and temporarily taking control of the mouse and keyboard. The implementation of the virtual computer lab model reported here was undertaken to address a practical need and was assessed using teaching evaluations. Future implementations of the model could more directly assess how extending the kinds of distant interaction impact transactional distance using measures of presence and sense of community as well. NLM will continue to explore using the method in other contexts. There is particular interest in trying the virtual computer lab methodology at other domestic and foreign sites, including those not having access to advanced networks.

Cn3D three dimensional molecular modeling viewer launched by clicking the image of the molecule retrievedFigure 2 Cn3D three dimensional molecular modeling viewer launched by clicking the image of the molecule retrieved.
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AcknowledgementsCompeting interestsThe author(s) declare that they have no competing interests.Authors' contributionsCL initiated the distance learning project, collaborated on the instructional and technical requirements, and generated the first draft of the manuscript. AV devised the VNC methodology for accessing student desktops and identified the VNC program meeting display and latency requirements. MB collaborated on the instructional and technical requirements and taught the courses. WL assisted AV in testing VNC programs and approaches. JC collaborated on the instructional and technical requirements and recruited students. All contributed to the further development of the manuscript. http://www.biomedcentral.com/1472-6920/8/12Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/8/12/prepub
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