A randomized prospective trial of an ostomy telehealth intervention for cancer survivors.

BACKGROUND: Cancer survivors with ostomies face complex challenges. This study compared the Ostomy Self-Management Telehealth program (OSMT) versus attention control usual care (UC). METHODS: Three academic centers randomized participants. OSMT group sessions were led by ostomy nurses and peer ostomates (three for ostomates-only, one for support persons, and one review session for both). Surveys at baseline, OSMT completion, and 6 months were primary outcome patient activation (PAM), self-efficacy (SE), City of Hope quality of life-Ostomy (COH-O), and Hospital Anxiety and Depression Scale (HADS). Surveys were scored per guidelines for those completing at least two surveys. Linear mixed effects models were used to select potential covariates for the final model and to test the impact of OSMT within each timeframe. RESULTS: A total of 90 OSMT and 101 UC fulfilled analysis criteria. Arms were well-matched but types of tumors were unevenly distributed (p = .023). The OSMT arm had a nonsignificant improvement in PAM (confidence interval [CI], -3.65 to 5.3]; 4.0 vs. 2.9) at 6 months. There were no significant differences in other surveys. There was a significant OSMT benefit for urinary tumors (four SE domains). Higher OSMT session attendance was associated with post-session improvements in five SE domains (p < .05), two COH-O domains (p < .05), and HADS anxiety (p = .01). At 6 months, there remained improvements in one SE domain (p < .05), one COH-O domain (p < .05), and HADS anxiety (p < .01). CONCLUSIONS: No clear benefit was seen for the OSMT intervention, although there may be an advantage based on type of tumor. Benefit with greater session attendance was also encouraging. PLAIN LANGUAGE SUMMARY: Cancer patients with ostomies have many challenges. We tested a telehealth curriculum compared to usual care. There are indications of benefit for the program for those that attend more sessions and those with urostomies.

The mechanics of cephalic furrow formation in the Drosophila embryo.

Cephalic furrow formation (CFF) is a major morphogenetic movement during gastrulation in Drosophila melanogaster embryos that gives rise to a deep, transitory epithelial invagination. Recent studies have identified the individual cell shape changes that drive the initiation and progression phases of CFF; however, the underlying mechanics are not yet well understood. During the progression phase, the furrow deepens as columnar cells from both the anterior and posterior directions fold inwards rotating by 90°. To analyze the mechanics of this process, we have developed an advanced two-dimensional lateral vertex model that includes multinode representation of cellular membranes and allows us to capture the membrane curvature associated with pressure variation. Our investigations reveal some key potential mechanical features of CFF, as follows. When cells begin to roll over the cephalic furrow cleft, they become wedge shaped as their apical cortices and overlying membranes expand, lateral cortices and overlying membranes release tension, internal pressures drop, and basal cortices and membranes contract. Then, cells reverse this process by shortening apical cortices and membranes, increasing lateral tension, and causing internal pressures to rise. Since the basal membranes expand, the cells recover their rotated columnar shape once in the furrow. Interestingly, our findings indicate that the basal membranes may be passively reactive throughout the progression phase. We also find that the smooth rolling of cells over the cephalic furrow cleft necessitates that internalized cells provide a solid base through high levels of membrane tension and internal pressure, which allows the transmission of tensile force that pulls new cells into the furrow. These results lead us to suggest that CFF helps to establish a baseline tension across the apical surface of the embryo to facilitate cellular coordination of other morphogenetic movements via mechanical stress feedback mechanisms.

Intimacy and survivors of cancer with ostomies: findings from the Ostomy Self-management Training trial.

BACKGROUND: Many people with abdominal or pelvic cancers require an ostomy during surgical treatment, which can cause significant issues with physical and emotional intimacy in relationships. AIM: To evaluate the effect of a telehealth-based education program on intimacy over time for survivors of cancer with ostomies. METHODS: We performed a secondary analysis of our multicenter randomized controlled trial to determine intimacy outcomes and to compare the effects of the Ostomy Self-management Training (OSMT) program vs usual care. Partnered patients were included who provided answers to the City of Hope Quality of Life-Ostomy survey for at least 2 time points during the study. We evaluated the effect of baseline information, such as gender on intimacy. OUTCOMES: The primary outcome was intimacy, estimated by a composite score created from questions within the City of Hope Quality of Life-Ostomy survey. RESULTS: Of 216 enrolled volunteers, 131 had a partner: 68 in the OSMT arm and 63 in the usual care arm. Of these, 48 were women and 83 were men. The tumor types represented in this study were colorectal (n = 69), urinary (n = 45), gynecologic (n = 10), and other (n = 7; eg, melanoma, liposarcoma). From the cohort, 87 answered the 5 composite intimacy score questions at 2 time points, including baseline. There was significant improvement over time in composite intimacy scores for participants in the OSMT arm vs the usual care arm. CLINICAL IMPLICATIONS: Our OSMT intervention had a positive effect on factors that contribute to intimacy for survivors of cancer with ostomies, suggesting that a survivorship curriculum can improve their experiences after ostomy surgery. STRENGTHS AND LIMITATIONS: OSMT allowed for discussion of intimacy and other sensitive topics, which can be challenging. These discussions demonstrate benefit to participants and can serve as frameworks for cancer treatment providers. The focus of this work on partnered participants provides insight into the interpersonal challenges of a life with an ostomy, but it may overlook the important perspectives of nonpartnered participants and the partners themselves. Furthermore, limited power prevented us from conducting subgroup analyses exploring the effects of factors such as gender and tumor type on intimacy. CONCLUSION: At 6-month follow-up, the novel intimacy composite score indicated improvement for participants completing the OSMT intervention. Future research studies with higher power will validate this intimacy measurement and identify intimacy differences in similar populations based on tumor type.

Clinical and Demographic Differences Among Cancer Survivors With Ostomies With and Without Informal Caregivers.

Informal caregivers have an essential role for cancer survivors (CS). There may be important clinical and demographic differences between CS with ostomies based on caregiver status. Our aim was to identify items that may lead to future recommendations and interventions for CS with ostomies. This is a secondary analysis of 216 CS with ostomies that were enrolled in a clinical trial. Baseline data collected included demographics, clinical characteristics, and surveys (patient activation, self-efficacy, City of Hope Quality of Life - Ostomy). These factors were compared based on caregiver status using chi-squared analysis and t-tests. Logistic regression was used to examine the factors that affect the likelihood of having a caregiver. Most participants had an identified caregiver (57%; 124/216). There was no difference in age based on caregiver status (mean 64.4 and 62.0 for those with and without a caregiver, respectively). Of those with a caregiver, 66.9% were males, 79.0% were partnered, and 87.1% were white. Those with caregivers had a higher prevalence of diabetes (p < 0.001), heart disease (p = 0.002), and mobility issues (p = 0.002). Survivors with caregivers had both higher incomes (p = 0.012) and levels of education (p = 0.049). The only difference in survey measures was those with a caregiver were more successful at getting help when needed (p = .045). Differences in gender and comorbidities of CS with caregivers demand further investigation. Interventions such as encouraging CS without caregivers to utilize available sources of social support, including other survivors with ostomies, may improve their care and quality of life.

Mechanical feedback and robustness of apical constrictions in Drosophila embryo ventral furrow formation.

Formation of the ventral furrow in the Drosophila embryo relies on the apical constriction of cells in the ventral region to produce bending forces that drive tissue invagination. In our recent paper we observed that apical constrictions during the initial phase of ventral furrow formation produce elongated patterns of cellular constriction chains prior to invagination and argued that these are indicative of tensile stress feedback. Here, we quantitatively analyze the constriction patterns preceding ventral furrow formation and find that they are consistent with the predictions of our active-granular-fluid model of a monolayer of mechanically coupled stress-sensitive constricting particles. Our model shows that tensile feedback causes constriction chains to develop along underlying precursor tensile stress chains that gradually strengthen with subsequent cellular constrictions. As seen in both our model and available optogenetic experiments, this mechanism allows constriction chains to penetrate or circumvent zones of reduced cell contractility, thus increasing the robustness of ventral furrow formation to spatial variation of cell contractility by rescuing cellular constrictions in the disrupted regions.

Adapting to the burdens of care: a telehealth program for cancer survivors with ostomies.

PURPOSE: An ostomy introduces to cancer survivors new demands for self-care and healthcare resource use. A curriculum that teaches ostomates self-management skills may affect survivors' use of resources. METHODS: A prospective randomized trial comparing usual care (UC) with an Ostomy Self-Management Training (OSMT) program delivered by telehealth was conducted in patients with ostomies due to cancer. The intervention occurred over 5 weeks with survey administration at baseline, program completion, and 6 months after completion. Quantitative data were analyzed using a mixed-effects logistic model to predict mean values of resource and service use. Responses to the open-ended question were coded and analyzed with directed content analysis. RESULTS: One hundred and sixty-seven subjects (89 in the OSMT arm and 78 in the UC arm) completed the questionnaire at all time points. The changes in likelihoods of emptying one's ostomy bag > 8 times/week and of incurring any out-of-pocket costs on accessories were 14% greater for the intervention group (p = .029 and p = .063, respectively). Qualitative analysis reveals among the OSMT arm an increase in the proportion of ostomy-specific comments and a decrease in the same metric among the UC arm. Common themes included learning to work with equipment, dealing with gas build-up and finding well-fitting clothing. CONCLUSIONS: There are some indications that participants in this structured telehealth program are more active in ostomy self-care. The reported ostomy self-care activities, healthcare consumables, and healthcare services reported by both groups illustrate the complexity of survivorship care following ostomy surgery. National Clinical Trial Identifier: NCT02974634.

Stakeholder engagement and participation in the design, delivery, and dissemination of the ostomy self-management telehealth (OSMT) program.

PURPOSE: Stakeholder engagement is increasingly integrated into clinical research processes. We conducted a mixed methods analysis to describe stakeholders' (peer ostomates, ostomy nurses, telehealth engineers) perceptions of their engagement and participation in a multisite, randomized trial of a telehealth-delivered curriculum for cancer survivors with ostomies. METHODS: Stakeholder notes were analyzed using narrative analysis. We constructed a 15-item survey that assessed the following areas: adherence to stakeholder engagement principles, engagement/influence throughout the study process, impact on perceived well-being, and satisfaction. Stakeholders were invited to complete the survey anonymously. Quantitative survey data were tabulated through summary statistics. RESULTS: Across intervention sessions, an average of 7.7 ± 1.4 stakeholders attended and 2.6 ± 1.4 submitted a note per session. The survey response rate was 73% (11/15). Stakeholders reported high agreement that the study adhered to engagement principles (91% reciprocal relationships, 100% co-learning, partnership, and transparency/honesty/trust). They felt highly engaged (18% moderate, 73% great deal) and that they had influence on study initiation (27% moderate, 55% great deal), intervention delivery (9% moderate, 82% great deal), fidelity assessment (18% moderate, 73% great deal), analysis and interpretation (55% moderate, 27% great deal), and dissemination (45% moderate, 45% great deal). They reported high overall satisfaction with roles (91% great deal), believed the program was helpful for participants (91%), and that serving on study team benefited their own well-being (100%). CONCLUSIONS: Our strategy of stakeholder inclusion led to high engagement, input, satisfaction, and belief in success of program, which could be mirrored in other trials.

Cancer survivors' greatest challenges of living with an ostomy: findings from the Ostomy Self-Management Telehealth (OSMT) randomized trial.

OBJECTIVES: An ostomy results in lifelong quality of life changes for a cancer survivor. We describe the greatest challenges reported from a randomized trial of cancer survivors with stomas (ostomies). METHODS: Cancer survivors with ostomies participating in a multi-site randomized prospective trial of an Ostomy Self-Management Telehealth (OSMT) program versus usual care (UC) were surveyed at six months post accrual. An open-ended question requested greatest challenges after ostomy surgery. Quantitative descriptive and qualitative analyses were used to examine greatest challenges reported. RESULTS: A total of 118 trial participants identified greatest challenges with 55 in the OSMT and 63 in the UC. Six conceptual domains were used to code comments-physical, psychological, social, and spiritual quality of life; ostomy-specific issues, and healthcare issues. The OSMT contributed 187 comments, and UC contributed 235 comments. Ostomy specific issues and social well-being had the most comments overall with UC contributing more comments in all domains except physical well-being. Word Clouds revealed post-operative and treatment-related issues and going out in public as the most common challenges in both groups. Word Clouds compared types of ostomies revealing bowel function challenges (colostomy group), difficulties going out in public (ileostomy group), and positive support (urostomy group). CONCLUSIONS: Fewer challenges submitted by the OSMT group provide the beginning evidence of the OSMT program impact. Dominant challenges across both groups were social well-being and ostomy care. Challenges varied by type of ostomy. Findings support long-term care and support for all cancer survivors with ostomies. TRIAL REGISTRATION: NCT02974634.

A Silver Lining? Fewer Non-Severe Acute Respiratory Syndrome Coronavirus 2 Respiratory Viruses During the Coronavirus Disease 2019 Pandemic.

Nonpharmaceutical interventions (NPIs) have "flattened the curve" of the coronavirus disease 2019 pandemic; however the effect of these interventions on other respiratory viruses is unknown. We used aggregate level case count data for 8 respiratory viruses and compared the institutional and statewide case counts before and during the period that NPIs were active. We observed a 61% decrease (incidence rate ratio, 0.39; 95% confidence interval, .37-.41; P < .001) in non-severe acute respiratory syndrome coronavirus 2 respiratory viral infections when NPIs were implemented. This finding, if further verified, should guide future public health initiatives to mitigate viral epidemics.

Programmatic Costs of the Telehealth Ostomy Self-Management Training: An Application of Time-Driven Activity-Based Costing.

OBJECTIVES: Programmatic cost assessment of novel clinical interventions can inform their widespread dissemination and implementation. This study aimed to determine the programmatic costs of a telehealth Ostomy Self-Management Training (OSMT) intervention for cancer survivors using Time-Driven Activity-Based Costing (TDABC) methodology. METHODS: We demonstrated a step-by-step application of TDABC based on a process map with core OSMT intervention activities and associated procedures and determined resource use and costs, per unit procedure. We also assessed per-patient costs from a payer perspective and provided estimates of total hours and costs by personnel, activity, and procedure. RESULTS: The per-patient cost of the OSMT was $1758. Personnel time accounted for 91% of the total cost. Site supervisor and information technology technician time were the most expensive personnel resources. Telehealth technical and communication equipment accounted for 8% of the total cost. Intervention coordination and monitoring efforts represented most of the total time cost (62%), followed by the intervention delivery (35%). The procedures with the highest cost were communication via phone or virtual meetings (24%), email exchanges (18%), and telehealth session delivery (18%). CONCLUSIONS: Future efforts to replicate, disseminate, and implement the OSMT intervention should anticipate funding for nonclinical components of the intervention, including coordination and monitoring, and consider how these activities can be performed most efficiently. For institutions without established telemedicine programs, selection of videoconferencing platforms and adequate staffing for participant technical support should be considered. Our step-by-step application of TDABC serves as a case study demonstrating how interventionists can gather data on resource use and costs of intervention activities concurrently with their collection of trial data.

An Ostomy Self-management Telehealth Intervention for Cancer Survivors: Technology-Related Findings From a Randomized Controlled Trial.

BACKGROUND: An Ostomy Self-management Telehealth (OSMT) intervention by nurse educators and peer ostomates can equip new ostomates with critical knowledge regarding ostomy care. A telehealth technology assessment aim was to measure telehealth engineer support requirements for telehealth technology-related (TTR) incidents encountered during OSMT intervention sessions held via a secure cloud-based videoconferencing service, Zoom for Healthcare. OBJECTIVE: This paper examines technology-related challenges, issues, and opportunities encountered in the use of telehealth in a randomized controlled trial intervention for cancer survivors living with a permanent ostomy. METHODS: The Arizona Telemedicine Program provided telehealth engineering support for 105 OSMT sessions, scheduled for 90 to 120 minutes each, over a 2-year period. The OSMT groups included up to 15 participants, comprising 4-6 ostomates, 4-6 peer ostomates, 2 nurse educators, and 1 telehealth engineer. OSMT-session TTR incidents were recorded contemporaneously in detailed notes by the research staff. TTR incidents were categorized and tallied. RESULTS: A total of 97.1% (102/105) OSMT sessions were completed as scheduled. In total, 3 OSMT sessions were not held owing to non-technology-related reasons. Of the 93 ostomates who participated in OSMT sessions, 80 (86%) completed their OSMT curriculum. TTR incidents occurred in 36.3% (37/102) of the completed sessions with varying disruptive impacts. No sessions were canceled or rescheduled because of TTR incidents. Disruptions from TTR incidents were minimized by following the TTR incident prevention and incident response plans. CONCLUSIONS: Telehealth videoconferencing technology can enable ostomates to participate in ostomy self-management education by incorporating dedicated telehealth engineering support. Potentially, OSMT greatly expands the availability of ostomy self-management education for new ostomates. TRIAL REGISTRATION: ClinicalTrials.gov NCT02974634; https://clinicaltrials.gov/ct2/show/NCT02974634.

Reading List: Select Healthcare Transformation Library 2.0.

Reading List: Select Healthcare Transformation Library 2.0 represents a broad-based, annotated, general reading list for students of health care innovation. The books were drawn from the 5,000-book private home library of Ronald S. Weinstein, MD, President Emeritus of the American Telemedicine Association. Weinstein is a lifelong book collector with special interests in the history of medical innovation and poetry. A Massachusetts General Hospital-trained pathologist and inductee into the US Distance Learning Association's Hall of Fame, he is known as a pioneer in telemedicine and the "father of telepathology" for his invention, patenting, and commercialization of telepathology, a subspecialty of telemedicine that is a billion-dollar worldwide industry today. This Reading List: Select Healthcare Transformation Library 2.0 consists of 41 books divided into 10 sections: (1) Human Intelligence, Behavior, and Creativity; (2) Societal Revolutions; (3) Innovation; (4) Healthcare System Transformations; (5) Education; (6) Transformational Technologies-Part 1 (AI, Automation, and Robotics); (7) Transformational Technologies-Part 2 (Telemedicine and Telehealth); (8) Digital Medicine; (9) Healthcare Transformation Implementation; and (10) COVID-19 Pandemic as an Innovation Accelerator.

pH homeostasis during coral calcification in a free ocean CO2 enrichment (FOCE) experiment, Heron Island reef flat, Great Barrier Reef.

Geochemical analyses (δ(11)B and Sr/Ca) are reported for the coral Porites cylindrica grown within a free ocean carbon enrichment (FOCE) experiment, conducted on the Heron Island reef flat (Great Barrier Reef) for a 6-mo period from June to early December 2010. The FOCE experiment was designed to simulate the effects of CO2-driven acidification predicted to occur by the end of this century (scenario RCP4.5) while simultaneously maintaining the exposure of corals to natural variations in their environment under in situ conditions. Analyses of skeletal growth (measured from extension rates and skeletal density) showed no systematic differences between low-pH FOCE treatments (ΔpH = ∼-0.05 to -0.25 units below ambient) and present day controls (ΔpH = 0) for calcification rates or the pH of the calcifying fluid (pHcf); the latter was derived from boron isotopic compositions (δ(11)B) of the coral skeleton. Furthermore, individual nubbins exhibited near constant δ(11)B compositions along their primary apical growth axes (±0.02 pHcf units) regardless of the season or treatment. Thus, under the highly dynamic conditions of the Heron Island reef flat, P. cylindrica up-regulated the pH of its calcifying fluid (pHcf ∼8.4-8.6), with each nubbin having near-constant pHcf values independent of the large natural seasonal fluctuations of the reef flat waters (pH ∼7.7 to ∼8.3) or the superimposed FOCE treatments. This newly discovered phenomenon of pH homeostasis during calcification indicates that coral living in highly dynamic environments exert strong physiological controls on the carbonate chemistry of their calcifying fluid, implying a high degree of resilience to ocean acidification within the investigated ranges.

Impact of seawater acidification on pH at the tissue-skeleton interface and calcification in reef corals.

Insight into the response of reef corals and other major marine calcifiers to ocean acidification is limited by a lack of knowledge about how seawater pH and carbonate chemistry impact the physiological processes that drive biomineralization. Ocean acidification is proposed to reduce calcification rates in corals by causing declines in internal pH at the calcifying tissue-skeleton interface where biomineralization takes place. Here, we performed an in vivo study on how partial-pressure CO(2)-driven seawater acidification impacts intracellular pH in coral calcifying cells and extracellular pH in the fluid at the tissue-skeleton interface [subcalicoblastic medium (SCM)] in the coral Stylophora pistillata. We also measured calcification in corals grown under the same conditions of seawater acidification by measuring lateral growth of colonies and growth of aragonite crystals under the calcifying tissue. Our findings confirm that seawater acidification decreases pH of the SCM, but this decrease is gradual relative to the surrounding seawater, leading to an increasing pH gradient between the SCM and seawater. Reductions in calcification rate, both at the level of crystals and whole colonies, were only observed in our lowest pH treatment when pH was significantly depressed in the calcifying cells in addition to the SCM. Overall, our findings suggest that reef corals may mitigate the effects of seawater acidification by regulating pH in the SCM, but they also highlight the role of calcifying cell pH homeostasis in determining the response of reef corals to changes in external seawater pH and carbonate chemistry.

Rapid, high-precision measurements of boron isotopic compositions in marine carbonates.

RATIONALE: The isotopic composition and elemental abundance of boron (B) in marine carbonates provide a powerful tool for tracking changes in seawater pH and carbonate chemistry. Progress in this field has, however, been hampered by the volatile nature of B, its persistent memory, and other uncertainties associated with conventional chemical extraction and mass spectrometric measurements. Here we show that for marine carbonates, these limitations can be overcome by using a simplified, low-blank, chemical extraction technique combined with robust multi-collector inductively couple plasma mass spectrometry (MC-ICPMS) methods. METHODS: Samples are dissolved in dilute HNO3 and loaded first onto on a cation-exchange column with the major cations (Ca, Mg, Sr, Na) being quantitatively retained while the B fraction is carried in the eluent. The eluent is then passed directly through an anion column ensuring that any residual anions, such as SO4(2-), are removed. Isotopic measurements of (11)B/(10)B ratios are undertaken by matching both the B concentration and the isotopic compositions of the samples with the bracketing standard, thereby minimising corrections for cross-contamination. RESULTS: The veracity of the MC-ICPMS procedure is demonstrated using a gravimetrically prepared laboratory standard, UWA24.7, relative to the international reference standard NIST SRM 951 (δ(11)B = 0‰). This gives values consistent with gravimetry (δ(11)B = 24.7 ± 0.3‰ 2sd) for solutions ranging in concentration from 50 to 500 ppb, equivalent to ~2-10 mg size coral samples. The overall integrity of the method for carbonate analysis is demonstrated by measurements of the international carbonate standard JCp-1 (δ(11)B = 24.3 ± 0.34‰ 2sd). CONCLUSIONS: A streamlined, integrated approach is described here that enables rapid, accurate, high-precision measurements of boron isotopic compositions and elemental abundances in commonly analysed biogenic carbonates, such as corals, bivalves, and large benthic forams. The overall simplicity of this robust approach should greatly facilitate the wider application of boron isotope geochemistry, especially to marine carbonates.

Testing a top-down strategy for establishing a sustainable telemedicine program in a developing country: the Arizona telemedicine program-US Army-Republic of Panama Initiative.

OBJECTIVE: Many developing countries have shown interest in embracing telemedicine and incorporating it into their healthcare systems. In 2000, the U.S. Army Yuma Proving Ground (YPG) initiated a program to assist the Republic of Panama in establishing a demonstration Panamanian rural telemedicine program. YPG engaged the Arizona Telemedicine Program (ATP) to participate in the development and implementation of the program. MATERIALS AND METHODS: The ATP recommended adoption of a "top-down" strategy for creating the program. Early buy-in of the Panamanian Ministry of Health and academic leaders was regarded as critical to the achievement of long-term success. RESULTS: High-level meetings with the Minister of Health and the Rectors (i.e., Presidents) of the national universities gained early program support. A telemedicine demonstration project was established on a mountainous Indian reservation 230 miles west of Panama City. Today, three rural telemedicine clinics are linked to a regional Ministry of Health hospital for teleconsultations. Real-time bidirectional videoconferencing utilizes videophones connected over Internet protocol networks at a data rate of 768 kilobits per second to the San Felix Hospital. Telepediatrics, tele-obstetrics, telepulmonology, teledermatology, and tele-emergency medicine services became available. Telemedicine services were provided to the three sites for a total of 1,013 cases, with numbers of cases increasing each year. These three demonstration sites remained in operation after discontinuation of the U.S. involvement in September 2009 and serve as a model program for other telemedicine initiatives in Panama. CONCLUSIONS: Access to the assets of a partner-nation was invaluable in the establishment of the first model telemedicine demonstration program in Panama. After 3 years, the Panamanian Telemedicine and Telehealth Program (PTTP) became self-sufficient. The successful achievement of sustainability of the PTTP after disengagement by the United States fits the Latifi-Weinstein model for establishing telemedicine programs in developing countries.

Enhanced flow rate by the concentration mechanism of Tetris particles when discharged from a hopper with an obstacle.

We apply a holistic two-dimensional (2D) Tetris-like model, where particles move based on prescribed rules, to investigate the flow rate enhancement from a hopper. This phenomenon was originally reported in the literature as a feature of placing an obstacle at an optimal location near the exit of a hopper discharging athermal granular particles under gravity. We find that this phenomenon is limited to a system of sufficiently many particles. In addition to the waiting room effect, another mechanism able to explain and create the flow rate enhancement is the concentration mechanism of particles on their way to reaching the hopper exit after passing the obstacle. We elucidate the concentration mechanism by decomposing the flow rate into its constituent variables: the local area packing fraction ϕ_{l}^{E} and the averaged particle velocity v_{y}^{E} at the hopper exit. In comparison to the case without an obstacle, our results show that an optimally placed obstacle can create a net flow rate enhancement of relatively weakly driven particles, caused by the exit-bottleneck coupling if ϕ_{l}^{E}>ϕ_{o}^{c}, where ϕ_{o}^{c} is a characteristic area packing fraction marking a transition from fast to slow flow regimes of Tetris particles. Utilizing the concentration mechanism by artificially guiding particles into the central sparse space under the obstacle or narrowing the hopper exit angle under the obstacle, we can create a manmade flow rate peak of relatively strongly driven particles that initially exhibit no flow rate peak. Additionally, the enhanced flow rate can be maximized by an optimal obstacle shape, particle acceleration rate toward the hopper exit, or exit geometry of the hopper.

Invention and Early History of Telepathology (1985-2000).

This narrative-based paper provides a first-person account of the early history of telepathology (1985-2000) by the field's inventor, Ronald S. Weinstein, M. D. During the 1980s, Dr. Weinstein, a Massachusetts General Hospital-trained pathologist, was director of the Central Pathology Laboratory (CPL) for the National Cancer Institute-funded National Bladder Cancer Project, located at Rush Medical College in Chicago, IL. The CPL did post therapy revalidations of surgical pathology and cytopathology diagnoses before outcomes of the completed clinical trials were published. The CPL reported that interobserver variability was invalidating inclusion of dozens of treated bladder cancer patients in published reports on treatment outcomes. This problem seemed ripe for a technology-assisted solution. In an effort to solve the interobserver variability problem, Dr. Weinstein devised a novel solution, dynamic-robotic telepathology, that would potentially enable CPL uropathologists to consult on distant uropathology cases in real-time before their assignment to urinary bladder cancer, tumor stage, and grade-specific clinical trials. During the same period, universities were ramping up their support for faculty entrepreneurism and creating in-house technology transfer organizations. Dr. Weinstein recognized telepathology as a potential growth industry. He and his sister, Beth Newburger, were a successful brother-sister entrepreneur team. Their PC-based education software business, OWLCAT™, had just been acquired by Digital Research Inc., a leading software company, located in California. With funding from the COMSAT Corporation, a publically traded satellite communications company, the Weinstein-Newburger team brought the earliest dynamic-robotic telepathology systems to market. Dynamic-robotic telepathology became a dominant telepathology technology in the late 1990s. Dr. Weinstein, a serial entrepreneur, continued to innovate and, with a team of optical scientists at The University of Arizona's College of Optical Sciences, developed the first sub-1-min whole-slide imaging system, the DMetrix DX-40 scanner, in the early 2000s.

Integrating telemedicine and telehealth: putting it all together.

Telemedicine and telehealth programs are inherently complex compared with their traditional on-site health care delivery counterparts. Relatively few organizations have developed sustainable, multi-specialty telemedicine programs, although single service programs, such as teleradiology and telepsychiatry programs, are common. A number of factors are barriers to the development of sustainable telemedicine and telehealth programs. First, starting programs is often challenging since relatively few organizations have, in house, a critical mass of individuals with the skill sets required to organize and manage a telemedicine program. Therefore, it is necessary to "boot strap" many of the start-up activities using available personnel. Another challenge is to assemble a management team that has time to champion telemedicine and telehealth while dealing with the broad range of issues that often confront telemedicine programs. Telemedicine programs housed within a single health care delivery system have advantages over programs that serve as umbrella telehealth organizations for multiple health care systems. Planning a telemedicine program can involve developing a shared vision among the participants, including the parent organizations, management, customers and the public. Developing shared visions can be a time-consuming, iterative process. Part of planning includes having the partnering organizations and their management teams reach a consensus on the initial program goals, priorities, strategies, and implementation plans. Staffing requirements of telemedicine and telehealth programs may be met by sharing existent resources, hiring additional personnel, or outsourcing activities. Business models, such as the Application Service Provider (ASP) model used by the Arizona Telemedicine Program, are designed to provide staffing flexibility by offering a combination of in-house and out-sourced services, depending on the needs of the individual participating health care organizations. Telemedicine programs should perform ongoing assessments of activities, ranging from service usage to quality of service assessments, to ongoing analyses of financial performance. The financial assessments should include evaluations of costs and benefits, coding issues, reimbursement, account receivables, bad debt and network utilization. Long-range strategic planning for a telemedicine and telehealth program should be carried out on an on-going basis and should include the program's governing board. This planning process should include goal setting and the periodic updating of the program's vision and mission statements. There can be additional special issues for multi-organization telemedicine and telehealth programs. For example, authority management can require the use of innovative approaches tailored to the realities of the organizational structures of the participating members. Inter-institutional relations may introduce additional issues when competing health care organizations are utilizing shared resources. Branding issues are preferably addressed during the initial planning of a multi-organizational telemedicine and telehealth program. Ideally, public policy regarding telemedicine and telehealth within a service region will complement the objectives of telemedicine and telehealth programs within that service area.