Establishment of a remote diagnostic histopathology service using whole slide imaging (digital pathology).

BACKGROUND: Whole slide imaging (WSI) has diverse applications in modern pathology practice, including providing histopathology services to remote locations. MATERIALS AND METHODS: Utilising an existing contractual partnership with a Northern Ontario group of hospitals, the feasibility of using WSI for primary diagnostic services from Toronto was explored by the dedicated working group. All aspects explored from information technology (IT), laboratory information system (LIS) integration, scanning needs, laboratory workflow and pathologist needs and training, were taken into account in the developing the rationale and business case. RESULTS: The financial outlay for a scanner was $CA180K (approximately £105.6 k) after discounts. There were no human resource requirements as staff were reorganised to cater for slide scanning. Additional IT/LIS costs were not incurred as existing connectivity was adapted to allow two site groups (gastrointestinal and skin) to pilot this study. Scanned slides were available for pathologist review 24-96 hours sooner than glass slides; there was a 2-day improvement for final authorised cases, and per annum savings were: $CA26 000 (£15.2 k) in courier costs, $CA60 000 (£35.2 k) travel and $CA45 000 (£26.4 k) in accommodation, meals and car rental expense. CONCLUSION: WSI is a viable solution to provide timely, high-quality and cost efficient histopathology services to underserviced, remote areas.

Use of a low-cost telecytopathology method for remote assessment of thyroid FNAs.

BACKGROUND: Rapid on-site evaluation is a great tool for optimizing the adequacy and quality of cytologic samples. The objective of the current study was to analyze a low-cost telecytopathology method for the remote assessment of thyroid fine-needle aspiration biopsies (FNABs), with comparison of the primarily rendered adequacy and diagnosis with the final conventional analysis. METHODS: Material collected from thyroid FNABs was immediately smeared onto glass slides and stained with Diff-Quik. A conventional microscope attached to a smart device was operated on-site by either a medical student or a pathology resident for Wi-Fi transmission of the images by Skype. The cytopathologist would remotely guide the screening of the slides, zooming in and out of areas of interest. Remote assessment included an analysis of material adequacy and a preliminary diagnosis. The quality of the transmission and the number of slides also were recorded. After a washout period of 3 weeks, final diagnosis and adequacy were assigned by conventional microscopy. RESULTS: The final agreement rate for adequacy between remote and conventional analysis was 90.5%. For diagnosis, the final agreement rate was 83.3%. The diagnosis agreement rate varied, depending on the quality of transmission: there was 88% agreement when the quality was excellent, 77.8% agreement when it was good, and 62.5% agreement when it was poor. CONCLUSIONS: Low-cost telecytopathology is an efficient method for the remote assessment of thyroid FNAB adequacy and diagnosis. The wide use of such technology in low-resource or remote centers may have a positive impact on the number of adequate or satisfactory samples, optimizing the management of patients who have thyroid nodules.

New Technologies: Real-time Telepathology Systems-Novel Cost-effective Tools for Real-time Consultation and Data Sharing.

Real-time telepathology for use in investigative and regulated preclinical toxicology studies is now feasible. Newly developed microscope-integrated telepathology systems enable geographically remote stakeholders to view the live histopathology slide as seen by the study pathologist within the microscope. Simultaneous online viewing and dialog between study pathologist and remote colleagues is an efficient and cost-effective means for consultation, pathology working groups, and peer review, facilitating good science and economic benefits by enabling more timely and informed clinical decisions.

Design of New Procedures for Diagnosing Prevalent Diseases Using a Low-Cost Telemicroscopy System.

BACKGROUND: Currently, the diagnosis of prevalent diseases such as malaria, tuberculosis, or diarrheal diseases in rural areas of developing countries requires the displacement of the patient from their community health post to their reference health center or to ship a sample. This delays diagnosis and the treatment of disease. OBJECTIVE: Conduct research to develop a new method for rapid low-cost diagnosis of prevalent diseases in rural areas of developing countries (malaria, tuberculosis, parasitic infections, vaginal infections, and cervical cancer). METHODS: The study was divided into three phases. The first related to the drafting and validating of new protocols for the preparation of samples that should be adapted to be carried out in areas without power and with little trained personnel. The second phase consisted of developing a telemicroscopy system looking for low cost, software compatibility, and technical quality. Finally, the third phase evaluated the system as a diagnostic tool using direct observation with a conventional microscope as the gold standard. RESULTS: The validation of the new protocols showed that 100% of the vaginal swabs were processed correctly when using direct smear, while they were only 86.3% correct when using Gram stain; 68.3% of fecal samples were correctly processed using Kinyoun stain; 61.7% of blood samples when using thin film; and 83.8% when using thick film. Phase 2 permitted the development of a low-cost (<$250) and low-power (<15 W) telemicroscopy system that allows real-time consultation between health technicians and specialists. Finally, phase 3 proved that there was no difference between the diagnostics obtained by direct observation in a microscope and those ones obtained through the new telemicroscopy system. CONCLUSIONS: This study has verified the effectiveness of the telemicroscopy system as a diagnostic tool, given the complete agreement between the diagnoses made with it and those made with the gold standard.

Los orígenes caribeños del Sistema Nacional de Salud Pública en los EEUU: una aproximación global a la historia de la medicina y de la salud pública en Latinoamérica / The Caribbean origins of the National Public Health System in the USA: a global approach to the history of medicine and public health in Latin America

Este artículo define la historia global en relación con historia de la medicina y la salud pública. Defiende que una aproximación global a la historia abre un espacio para reverberaciones transmitidas desde la periferia geográfica hacia regiones occidentales, las cuales, tradicionalmente, han dominado la historiografía moderna. Analiza dos intervenciones médicas, en el Caribe, a finales del siglo XIX y principios del XX, y señala que estos sucesos tuvieron profundas consecuencias en los EEUU. Los logros alcanzados en el Caribe, en lo relativo al control de la fiebre amarilla y del anquilostoma, además de servir de modelo para campañas sanitarias en el sur de los EEUU, impulsaron la centralización de la salud pública norteamericana bajo el control centralizador del gobierno federal.

This article defines global history in relation to the history of medicine and public health. It argues that a global approach to history opens up a space for examining the reverberations transmitted from the geographic periphery towards western regions, which have traditionally dominated modern historiography. It analyzes two medical interventions in the Caribbean in the late nineteenth and early twentieth century, showing how these events had profound consequences in the USA. The successes achieved in the Caribbean in terms of yellow fever and ancylostoma control, as well as providing a model for health campaigns in the southern USA, inspired the centralization of public health in North America under the centralizing control of the federal government.

Obstacles hindering the mainstream practice of teledermatopathology.

BACKGROUND: Teledermatopathology has the potential to link underserved areas to experts across the country and assist in making quick diagnoses, which may improve health care costs and delivery. Despite these potential benefits, teledermatopathology is not used routinely for primary diagnosis in the United States. OBJECTIVE: To assess the current status of and address the potential for improving health care by the use of teledermatolopathology for primary diagnosis. METHODS: Current available literature and online resources were reviewed to address 3 major variables that hinder the widespread use of teledermatopathology: diagnostic accuracy, licensure requirements, and reimbursement. RESULTS: Recent studies show similar diagnostic accuracy for this technology compared to conventional microscopy. State-to-state variation and ambiguity in laws serve as the biggest hurdles to the widespread use of teledermatopathology. More states are recognizing the importance of the implementation of specific laws regarding telemedicine. More studies are required to evaluate the systems that offer specific telemedicine licenses, in addition to those that pay for telemedicine services specifically. LIMITATIONS: This study reviewed current legislation concerning teledermatopathology; these laws are subject to revision. CONCLUSION: Improving diagnostic accuracy and limiting variations in policy and reimbursement may encourage more pathologists to use teledermatopathology technology.

Virtual slide telepathology with scanner systems for intraoperative frozen-section consultation.

Telepathology provides pathology services over a distance using digital imaging and telecommunication for primary diagnostic practice, including intraoperative frozen sections. Virtual slide technology provides digitizing of histological slides by scanner systems and improved remote assessment substantially. In this retrospective study, diagnostic accuracy of intraoperative frozen sections assessed as virtual slide was determined. Tissue assessment was mainly requested for urological, gynecological and dermatological resections. Issues of time consumption, cost and cost effectiveness of this diagnostic method are discussed. 1204 intraoperative frozen sections were conducted in the course of this study at our department over a period of 2.5 years. 98.59% of all intraoperative frozen sections were accurately diagnosed in the initial telepathological assessment. Tumor affection was present in 15.6% of frozen sections, in 174 instances already assessed in the initial slides (sensitivity 92.6%). Discrepant diagnoses compared to the final diagnosis occurred in 1.41%. Our determined averaged time for virtual slide technology of 10.58±8.19min can be ranged in well. Our study did not allow a full economic assessment, but some preliminary insights are pointed out. The quality of services is highly acceptable and the investment costs and the labor cost of virtual slide technology are lower than those of robotic microscopy.

Remote and rapid pathological diagnosis in a resource challenged unit.

Malawi is one of the world's poorest countries, but despite this, has a dedicated paediatric oncology service. The service has been hampered by the inability to make a timely cytological diagnosis in the majority of patients. A telemedicine programme was commenced to help overcome this problem, and the results for the first 197 consecutive patients are described. The results are compared with the local reports where available. Most samples were fine needle aspirates (104/197-53%), but others included bone marrow aspirates, peripheral blood films and other fluid collections. A diagnosis was arrived at in 52% of the samples; there were 46 discordant results, 38 were when one or other of the local or distant teams were unable to make a diagnosis, and only 8 where the diagnoses of the 2 teams differed. Diagnoses were made and reports were compiled by the 'distant' team within 24 h and sent to the centre in Malawi. This simple telepathology initiative has had a positive impact on clinical management, and could be used in other less resourced centres twinned with better resourced ones.

A comprehensive analysis of a web-based dermatopathology second opinion consultation practice.

CONTEXT: Sharing cases and seeking second opinion consultations is an important part of everyday pathology practice. Internet-based communications and upcoming digital slide technologies have the potential to decrease barriers and open access to the best expertise. We recently developed a dedicated Web-based process for communication with outside practices seeking second opinion consultations. The software allowed us to collect data about the current needs and use of a second opinion consultation practice, a topic that has not been addressed in research studies thus far. OBJECTIVE: To analyze the needs for and performance of a Web-based second opinion consultation practice in dermatopathology. DESIGN: We performed a retrospective analysis on paper and digital records. RESULTS: The average turn-around time from the time of biopsy to the time the report was issued was 7-days. Eighty-two percent of cases were reported the same day they were received. Biopsies of melanocytic lesions, inflammatory dermatoses, and squamous lesions comprised 82% of consultations. Among the remaining cases, soft tissue tumors, adnexal neoplasms, alopecia, and nonmelanoma nonsquamous lesions were the most common diagnoses. In 69% of cases, the outside report contained information about the diagnosis favored by the submitting pathologists. In 5%, there was a significant change in the diagnosis. CONCLUSIONS: Web-based communication facilitates rapid turn-around time and reduces costs and barriers to second opinion consultation.

Forecast on the application of Japanese universal service fund to remote diagnosis for frozen section.

Due to the socioeconomic reason in Japan, some cancer patient is sometimes operated at a rural hospital where only several surgeons perform and no pathologist checks its malignancy. Therefore, the system of the remote diagnosis for frozen section has been standing up in this country for 7 years. In Japan, the USF has started from February 2007 to support only telecommunications operator's hardware (NTT's equipment such as digital switch board) in high cost areas, not for the reimbursement of the tariff of the public users, such as telepathology. To solve such social cormorant equality, when the USF and PAs were supported in the present quick frozen intraoperative telepathology diagnosis, the quality of the cancer treatment in rural area will be improved. Based on the past data of the Japanese telepathology with beta distribution function, it can be estimated that user terminals becomes five times more than present users with support of USF and PAs. Moreover, using VPN on the B'FLETS, the effect of other teleconsultations will spread to the nationwide.

Telepathology for patient care: what am I getting myself into?

The vast advancements in telecommunications and converting medical information to a digital format have increased the number of applications within telemedicine. Telepathology, in simplest terms, is the practice of formally rendering a pathologic diagnosis based upon examination of an image rather than of a glass slide through traditional microscopy. The use of telepathology for clinical patient care has so far been limited to relatively few large academic institutions. Although a number of challenges remain, there is increasing demand for the use of information technology in pathology as a whole owing to the expansion of health care networks and the opportunity to enhance the quality of service delivered to patients. The software used to acquire, display, and manage digital images for clinical patient care may be subject to national and federal regulations just as is any other electronic information system. Despite the barriers, telepathology systems possess the capability to help manage pathology cases on a global scale, improve laboratory workload distribution, increase standardization of practice and enable new classes of ancillary studies to facilitate diagnosis and education even in the most remote parts of the earth.

Low-cost telepathology system for intraoperative frozen-section consultation: our experience and review of the literature.

We have established a low-cost noncommercial system of dynamic real-time telepathology for light microscopic diagnosis that was used to aid intradepartmental consultation for frozen-section diagnosis. Fifty cases were performed. For each case, multiple diagnoses were made and compared, namely, those made by the pathologist on duty (D1), by a subspecialist or senior using telepathology (D2), by the same pathologist using a light microscope (D3), and the final diagnosis (D4). A comparison of D1 and D2 revealed that 37 cases (74%) were diagnosed more precisely by D2. In 9 (18%) of 50 cases, there was a positive major impact on the operation as a result of teleconsultation. The results of D2 and D3 showed good agreement (kappa = 0.97). The average time span required for telepathology is short compared with routine intradepartmental consultation. Our experience showed that telepathology is a good tool for frozen-section consultation and imposes little additional cost.

A feasibility study of virtual slides in surgical pathology in China.

China's huge territorial expanse and its imbalance of regional economic development have resulted in an uneven distribution of experienced pathologists. Developing telepathology for consultation is of special relevance to China. We developed a newly designed telepathology workstation, which includes a small file size of each slide, permitting easy transmission, storage, and manipulation, and a feedback function, and also evaluated its feasibility in surgical pathology in China. Four hundred cases covering a broad spectrum of surgical pathology problems were investigated in a blinded fashion by the 2 pathologists using this virtual microscope system. These cases were then randomized and re-reviewed a second time with light microscope. Diagnoses and time spent for each diagnosis were recorded for both methods. The diagnostic accuracies achieved by viewing glass slides and virtual images were 97.25% (389 of 400) and 95.5% (382 of 400) for pathologist A and 96.25% (385 of 400) and 94.75% (379 of 400) for pathologist B, respectively. There was no significant diagnostic discrepancy between the 2 methods for the 2 pathologists. The average times for viewing a virtual slide were 3.41 and 5.24 minutes for pathologists A and B, respectively, whereas the average times for viewing a glass slide were 1.16 and 3.35 minutes for pathologists A and B. There was a statistical difference between the time costs of the 2 methods. However, the slight time increase using virtual slides is less than that using dynamic telepathology and traditional consultation, and is acceptable to the pathologists. These results showed that this newly designed virtual microscope system have an acceptable diagnostic accuracy that is of practical value and may be suitable for application in China.

Cost-effective dynamic telepathology in the Mohs surgery laboratory utilizing iChat AV videoconferencing software.

BACKGROUND: Dynamic telepathology is the real-time transmission of histologic images from one pathologist to another by means of telecommunications technology. OBJECTIVE: The objective was to determine whether dynamic telepathology can be accomplished accurately and inexpensively by use of readily available off-the-shelf consumer products and software. METHODS: We attached a standard, consumer-grade, digital video camera to a microscope in the Mohs surgery laboratory and then transmitted via the Internet real-time histologic video images and audio to a consultant dermatopathologist by means of iChat AV videoconferencing software (Apple Computer Inc., Cupertino, CA). In the first part of the study, 20 unknown formalin-fixed, paraffin-embedded slides from tumors typically seen in a Mohs practice were evaluated by the consultant dermatopathologist. In the second part of the study, the Mohs surgeon consulted the dermatopathologist on 20 Mohs frozen section slides in which the surgeon had a particular question (e.g., "Is this part of a pilosebaceous unit or is this basal cell carcinoma?"). RESULTS: The video images were adequate for pathologic interpretation. There was agreement between conventional light microscopy and dynamic telepathology diagnosis in 19 of 20 tumors. There was complete agreement for all 20 Mohs frozen section consultations. CONCLUSION: Dynamic telepathology can be accomplished accurately and inexpensively by use of readily available consumer products and software.

An economic evaluation of Japanese telemedicine, focusing on teleradiology and telepathology.

We collected information by postal survey from 622 medical institutions reported to be using telemedicine in Japan. The questionnaire asked about willingness to pay (WTP) for telemedicine and willingness to undertake (WTU) it. The Kernel Estimation Method was used to obtain WTP for teleradiology (4379 yen), telepathology (9526 yen), teleconferencing (2084 yen) and teleconsultation (633 yen). The estimated WTU were teleradiology (3875 yen), telepathology (17,918 yen), teleconferencing (3230 yen) and teleconsultation (3643 yen). These values are larger than the current charges that customers actually pay or providers receive. Multiplying these values by the number of medical institutions that had implemented telemedicine allows the total annual benefits of telemedicine to be estimated, e.g. for teleradiology, the annual benefit in terms of WTP and WTU (millions of yen per year) were 140.20 and 1101.75, respectively. Based on the results of the survey, specific policy measures to promote telemedicine further include improvement of quality and reimbursement.

Static telepathology consultation service between Tata Memorial Centre, Mumbai and Nargis Dutt Memorial Charitable Hospital, Barshi, Solapur, Maharashtra: an analysis of the first 100 cases.

Telepathology is the practice of pathology at a distance. Static telepathology is employed to achieve teleconsultation between a tertiary cancer referral centre, Tata Memorial Centre and a sister concern in rural area viz. Nargis Dutt Memorial Cancer Hospital, Barshi, Solapur. This is an analysis of the first 102 cases. Two transcontinental consultations have not been included in statistical analysis. A diagnosis was offered in 99 (99%) cases; whereas it was deferred in only I (1%) case. Clinically important or relevant diagnosis were achieved in 93/ 99 (93.93%) of cases. Major discrepancies were encountered in 6/99 (6.06%) of cases. A total of 79% of cases were reported within 3 days, of which 32% were reported within 8 hours (a single working day) and 47% within 1-3 days. Telemedicine can be used effectively to bridge the gap between medically underprivileged, geographically distant rural areas and advanced centers with technical expertise using cheaper static store and forward methodology.

Virtual slides: high-quality demand, physical limitations, and affordability.

Virtual slides (VSs) have been around since the beginning of telepathology. As recently as a couple of years ago, only single small images could be acquired, and their distribution was limited to e-mail at best. Today, whole slides can be acquired, covering an area up to 100,000 times larger than that possible only a few years ago. Moreover, advanced Internet and world-wide web technologies enable delivery of those images to a broad audience. Despite considerable advances in technology, few good examples of VSs for public use can be found on the web. One of the reasons for this is a lack of sophisticated and integrated commercial solutions covering the needs from acquisition to delivery at reasonable cost. This article describes physical and technical limitations of the VS technology to clarify the demands on a VS acquisition system. A new type of web-based VS viewer (vMic; http://alf3.urz.unibas.ch/vmic/) open to public use is introduced, allowing anyone to set up a VS system with high usability at low cost.

A cost comparison of telepathology and a visiting pathologist service.

We compared the costs of a dynamic, robotic telepathology service for intraoperative frozen sections with the cost of a once-weekly visiting pathologist service established between the small Reutte Hospital, located in north-western Tyrol, and the department of pathology of the University of Innsbruck. Telepathology required either 15 min or 30 min per case in order to make a diagnosis, depending on the type of tissue and the operator's experience in handling the telepathology system. Costs were calculated for a five-year period. The main costs of the telepathology service were for set-up, whereas the main costs of the visiting pathologist service concerned personnel. The threshold at which telepathology was cheaper than the visiting pathologist service was 46 cases per month (15 min for diagnosis) or 135 cases per month (30 min for diagnosis). The present case-load (eight cases per month) at the study hospital was below this threshold.