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PubMed1995

Digital video for networked CAL delivery.

Digital moving images (AVI format), were integrated into a specific computer-assisted learning (CAL) application, providing a highly visual and interactive self-learning tool in an area of the medical curriculum which is difficult to teach by traditional methods. This paper outlines the process used to obtain the digital video using relatively inexpensive equipment and the subsequent delivery over a university network without resorting to major upgrading of the network specifications.

Child Development↗
PubMed1998

Real-time telemedicine in the clinical assessment of the ocular surface.

PURPOSE: To report the feasibility of real-time video and audio transmission of slit-lamp images of the eye using conventional telephone systems. METHOD: We analyzed the feasibility and benefits of telemedicine in the diagnosis and follow-up of ocular surface disorders in referral patients using a real-time audio-video system that functions through integrated services digital network lines at a transmission speed of 384 kilobytes per second. RESULTS: Real-time slit-lamp images obtained through integrated services digital network lines offered satisfactory visual resolution of the ocular surface for the diagnosis and follow-up of ocular surface and corneal disease, while simultaneous audio transmission allowed for direct communication with the patient and attending physician when necessary. CONCLUSION: Telemedicine using conventional telecommunication infrastructures offers sufficient information for the diagnosis and follow-up of ocular surface disorders in referral patients.

Computer Communication Networks↗
PubMed1986

Computer networks for image management in radiology: an overview.

Currently, images obtained from digital radiographic modalities are archived and managed as analog images recorded on radiographic film. An alternative for total image management is a computer-based digital network. General design considerations for a digital image network are reviewed, and estimates of important system parameters are determined.

Computers↗
PubMed2003

Use of Joslin Vision Network digital-video nonmydriatic retinal imaging to assess diabetic retinopathy in a clinical program.

PURPOSE: To incorporate a nonmydriatic, digital-video retinal imaging system into a Diabetes Outpatient Intensive Treatment Program and to evaluate the system's ability to assess diabetic retinopathy (DR), determine follow-up, and appropriately refer to retinal specialist ophthalmologists. METHODS: Fundus images were obtained according to Joslin Vision Network (JVN) protocol and evaluated by certified JVN readers. Patients with significant retinal disease underwent evaluation by retinal specialists. RESULTS: A total of 268 (51.0%) of 525 imaged patients had comprehensive eye examination by a retinal specialist owing to referable JVN-assessed clinical level of DR, nondiabetic ocular disease, ungradeable images, last eye examination >/=12 months prior, or patient request for examination. JVN diagnosis of a clinical level of DR agreed exactly with clinical findings in 388 eyes (72.5%) or within one level in 478 eyes (89.3%). JVN referral based on most severe diagnosis in either eye matched retinal specialist-recommended follow-up in 248/268 of patients (92.5%). A total of 136/525 (25.9%) of JVN patients had nondiabetic ocular abnormalities requiring referral. CONCLUSIONS: Recommended follow-up from JVN imaging compared favorably to clinical examination by a retinal specialist. Nondiabetic ocular pathology was identified. JVN assessment of DR level compares favorably to clinical practice, potentially improving access to eye care and enhancing diabetes management.

Adolescent↗
PubMed1997

Validation of fetal telemedicine as a new obstetric imaging technique.

OBJECTIVE: Our purpose was to establish whether obstetric ultrasonography interpreted by a live video telemedicine link is comparable to interpretation by videotape review in a low-risk patient population. STUDY DESIGN: An Integrated Services Digital Network (ISDN 6) was established from three satellite offices to our central prenatal diagnostic center. Patients seen at these satellite offices had a complete fetal anatomic survey recorded onto videotape by a trained ultrasonographer. A live interactive video telemedicine link was then established to our center by the digital network, and a perinatologist directed the ultrasonographer through the anatomy survey. Subsequently a different perinatologist, blinded to the telemedicine interpretation, reviewed the videotaped examination. The reports from the videotaped and telemedicine scans were then compared on the basis of a score of 33 anatomic items. RESULTS: The first 200 patients seen at the satellite offices were included. Telemedicine and videotape interpretations provided similar scores in 84% of scans. In 17 of the 33 anatomic categories telemedicine provided significantly better scores than videotape, whereas in the remaining 16 anatomic categories the scores were equivalent. More videotape than telemedicine examinations required repeat ultrasonography because of suboptimal imaging (10% vs 3%, p = 0.003). CONCLUSIONS: The interpretation of obstetric ultrasonography with use of live video telemedicine is comparable to videotape review. Fetal telemedicine may prove to be a useful tool for providing ultrasonographic interpretation of fetal anatomy to a network of low-risk obstetric practices.

Feasibility Studies↗
PubMed2002

Impact of telemedicine on the practice of pediatric cardiology in community hospitals.

BACKGROUND: Tele-echocardiography has the potential to bring real-time diagnoses to neonatal facilities without in-house pediatric cardiologists. Many neonates in rural areas, smaller cities, and community hospitals do not have immediate access to pediatric sonographers or echocardiogram interpretation by pediatric cardiologists. This can result in suboptimal echocardiogram quality, delay in initiation of medical intervention, unnecessary patient transport, and increased medical expenditures. Telemedicine has been used with increased frequency to improve efficiency of pediatric cardiology care in hospitals that are not served by pediatric cardiologists. Initial reports suggest that telecardiology is accurate, improves patient care, is cost-effective, enhances echocardiogram quality, and prevents unnecessary transports of neonates in locations that are not served by pediatric cardiologists. OBJECTIVE: We report the largest series to evaluate the impact of telemedicine on delivery of pediatric cardiac care in community hospitals. We hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from community hospitals is accurate, improves patient care, enhances sonographer proficiency, allows for more efficient physician time management, increases patient referrals, and does not result in increased utilization of echocardiography. METHODS: Using desktop videoconferencing computers, pediatric cardiologists guided and interpreted pediatric echocardiograms from 2 community hospital nurseries 15 miles from a tertiary care center. Studies were transmitted in real-time using the H.320 videoconferencing protocol over 3 integrated services digital network lines (384 kilobits per second). This resulted in a frame rate of 23 to 30 frames per second. Sonographers who primarily scanned adult patients but had received additional training in echocardiography of infants performed the echocardiograms. Additional views were suggested as deemed necessary by the interpreting physician, and interpretations were made during the videoconference. The results of the echocardiogram and recommendations for patient care were communicated to the referring physician over the telemedicine system. Analyses of accuracy, patient treatment, echocardiogram quality, time to diagnosis, pediatric cardiologist practice time management, patient referral patterns, and echocardiography utilization were conducted prospectively. RESULTS: A total of 500 studies in 364 patients were transmitted during a 30-month period. The most common indication for echocardiography was to rule out congenital heart disease (208 of 500 studies). Signs and symptoms that prompted this concern included cyanosis, murmur, tachypnea, genetic syndrome, arrhythmia, abnormal fetal echocardiogram, and maternal diabetes. Other indications included suspected patent ductus arteriosus (PDA; 182 of 500 studies), intracardiac clot or catheter position, persistent pulmonary hypertension, and hemodynamic instability. Cardiac diagnoses included complex congenital heart disease (n = 16), noncritical heart disease (n = 107), and PDA (n = 86). Additional diagnoses included persistent pulmonary hypertension (n = 12), septal hypertrophy (n = 18), right atrial mass/clot/vegetation (n = 11), and decreased cardiac function (n = 6). An umbilical venous catheter was visualized in the left atrium in 9% (45 of 500) of all studies. No significant abnormalities were found in 244 studies. Major diagnoses were confirmed by subsequent review of videotape in all studies. Comparison of final videotape interpretation to initial telemedicine diagnosis resulted in 1 minor diagnostic change (membranous versus inlet ventricular septal defect). Echocardiograms were performed in subsequent visits in 264 patients. The diagnosis was altered in 3 patients. Telemedicine had an immediate impact on patient care in 151 transmissions. The most common interventions were indomethacin treatment for PDA (n = 76), retraction of umbilical venous catheters from the left atrium (n = 45), inotropic or anticongestive therapy (n = 19), anticoagulation (n = 8), and prostaglandin infusion (n = 8). Nineteen patients were transported to our hospital because of the telemedicine diagnosis. Inpatient or outpatient cardiology follow-up was recommended in an additional 131 studies and did not result in any change in the initial management. The most common diagnoses in these patients were ventricular septal defect (n = 56), atrial septal defect (n = 21), septal hypertrophy (n = 9), intracardiac thrombosis (n = 8), and pulmonary valve stenosis (n = 4). We speculate that the immediate availability of an echocardiographic diagnosis likely prevented unnecessary transport in 14 cases. Recommendations for additional views or adjustment of echocardiography machine settings were made in 95% of transmissions. Real-time guidance was especially helpful in suprasternal notch and subcostal sagittal imaging. Depth, color Doppler sector size, and color Doppler scale were frequently adjusted from routine adult settings during the teleconference. The average time from request for echocardiogram to completion of the videoconference was 28 +/- 14 minutes. This was significantly shorter than the waiting time (12 +/- 16 hours) for the videotape to be delivered by courier. Telemedicine eliminated the need for consultation in 194 cases and allowed the cardiologist to delay the visit until the end of the day in an additional 26 cases. This resulted in average time savings of 4.2 person-hours/wk based on travel and consultation time. Utilization of echocardiography was similar before (35 of 1000 births) and after (33 of 1000 to 43 of 1000) telemedicine installation. The percentage of neonatal echocardiograms that were interpreted by our practice increased from 63% to 81% at 1 hospital and from 0% to 100% at the other hospital. CONCLUSION: Real-time transmission of neonatal echocardiograms from community hospitals over 3 integrated services digital network lines is accurate and has the potential to improve patient care, enhance echocardiogram quality, aid sonographer education, and have a positive impact on referral patterns and time management without increasing the utilization of echocardiography.

Cardiology Service, Hospital↗
PubMed1990

Palmar-digital arterial networks in fifty pairs of human fetal hands: arteriographic models for clinical consideration.

Arterial networks in 50 pairs of human fetal hands, made visible by perfusion with radiopaque media, were compared between right and left hands. The imaged primary arterial networks in the fetal hands were also compared with those in adult human and rhesus monkey hands. It was found that superficial arch configurations and their primary ramifications are bilaterally similar in human fetal hands. The configurations of the primary arterial networks are established very early in prenatal growth and may be maintained into adulthood. The similarities in the arterial network arrangements between fetal human and rhesus monkey hands suggest that the rhesus monkey hand could provide an appropriate model for studies of surgical neurovascular anastomosis.

Angiography↗
PubMed2001

Trials and tribulations in deploying digital imaging network and picture archiving and communication system--film to filmless in 80 days.

The Naval Medical Center Portsmouth (NMCP) was constructed with the intention of deploying a picture archiving and communications system (PACS). All necessary infrastructures were installed and considerable planning was done during construction with the belief that this would make the deployment of the PACS much simpler. This was true during the early deployment; however, as time passed and the system was more heavily used, significant problems arose. User/operator-related and hardware/software-related problems were encountered. Although, most have been corrected, some have persisted and will require considerable manpower and/or fiscal resources to correct. The lesson learned is that no matter how much preparation is done for deploying PACS, many significant problems will surface as the system is used that will require the continued attention of the deployment project officer.

Computer Systems↗
PubMed1995

Evaluation of diffuse technologies: the case of digital imaging networks.

There have been significant developments in recent years in the methodologies and methods for the evaluation of a wide range of health technologies. There remain, though, many technologies which are difficult to evaluate. Often the difficulty stems from the complexity of the technologies themselves, which are in effect hybrids, comprising combinations of several distinct elements. In this paper these are termed 'diffuse' technologies, because the different elements exert different costs and effects, often across several different services. Computer networks are one, increasingly important, example of such technologies in health care. While it is possible to evaluate individual elements of such technologies, it is not clear how to evaluate the technology as a whole, where the whole may be greater (or less) than the sum of the parts. The paper outlines a seven-stage framework for the evaluation of diffuse technologies. The general principles of evaluation are illustrated using the example of picture archiving and communication systems (PACS), which are computer systems designed to capture, store and distribute electronic radiological images within a hospital.

Cost-Benefit Analysis↗
PubMed1994

Digital image communication using a public digital telephone network.

At the University Hospital in Malmö, a project concerning image communication has been started during 1992. At the hospital, the departments principally involved are the Departments of Radiation Physics, Diagnostic Radiology, Medical Technology and Clinical Physiology. The project goal is to develop a system for sending images--with little or no degradation of diagnostic information--during nights and weekends from the X-ray department to the home of an experienced radiologist on duty. The purpose is to shorten the time needed for diagnosis and decisions in acute situations. Up to now this has sometimes required that this radiologist has to turn up at the hospital, which can delay the diagnosis up to 0.5 h.

Computer Communication Networks↗
PubMed1989

Digital teleradiology: Seaforth--London network.

A total digital teleradiology system using a prototype DuPont laser beam scanner (DTR 2000) and a Bell Canada digital transmission network was evaluated. A total of 489 radiographic and ultrasonographic examinations were transmitted for interpretation from a 41-bed rural community hospital in Seaforth to the University Hospital in London, Ontario, 80 km away. There was concurrence in 98% of these examinations, i.e. the laser-sensitive facsimile film clearly duplicated the original film findings and allowed a confident interpretation to be made. We conclude that this system could readily serve the needs of family physicians in rural communities for radiologic consultation, diagnosis, management, and triage of patients 24 hours per day.

Evaluation Studies as Topic↗
PubMed1999

The GASTER project: building a computer network in digestive endoscopy: the experience of the European Society for Gastrointestinal Endoscopy. Gastrointestinal Endoscopy Application for Standards in Telecommunication, Education and Research.

Digestive endoscopy is currently the main diagnostic procedure for investigation of the digestive tract whenever a digestive disease is suspected. From 1970 to 1985, digestive endoscopy was performed with endoscopes equipped with fiberoptic bundles, whereas the last decade was marked by the development of electronic endoscopes, characterized by the presence of a CCD (charge coupled device) at the tip of the endoscope. Thus the physician looks at a TV screen to control the procedure and examine in detail the gut wall. Endoscopes examine the foregut until the duodenum and the hindgut, up to the three last intestinal loops. When the endoscopic workstation comprises a computer, it is possible to acquire electronic images during the endoscopy and use these images as support of the information about the results of the procedure. These numeric images can then be stored in databases containing text attached to them. Starting with these images, one may expect many developments in the near future that will change the management of the patient with digestive diseases. Physicians will become able to exchange images and text related to one patient or one procedure, although they are equipped with different workstations. Therefore, it is obvious that the information exchanged must be written in a standard format that makes it understandable by all systems. The European Society of Gastrointestinal Endoscopy is a scientific society that groups most of the gastroenterologists in Europe. This society has initiated a research program to develop standards for the exchange of images and text. The Gastrointestinal Endoscopy Applications for Standards in Telecommunication, Education, and Research (GASTER) project intends to implement a multimedia database of endoscopic images based on a standard format of images and a standard terminology for descriptive terms. These standards must be validated by use in different endoscopy units. The database will collect images from these centers that will be linked to the coordinating center through a network based on an integrated services digital network (fast electronic connection). This database will then be used for the development of computer applications. The output of the GASTER project will bring advances at three levels: (1) The physicians will be able to exchange images about the procedures their patients have undergone and will thus obtain more complete information, improving quality of care. They will also benefit from help-to-decision applications based on validated reference images from the database. (2) At the patient level, the quality of care will be improved through a better dissemination of information between the physicians in charge of the patient, thus there is better follow-up of the patient and a decrease in redundant examinations. (3) At the level of national health care systems, the benefit will be a decrease in cost of care due to a better follow-up of the patients, a decrease in redundant examinations, and a faster decision made to treat the patient. The possibility of consulting a database of a scientifically validated images used as reference material will also improve quality control in digestive endoscopy.

Computer Communication Networks↗
PubMed1996

[Boomerang flap. A true single-stage pedicled cross finger flap].

The indications for cover of long fingers have been considerably modified over recent years as a result of the concept of retrograde flow flaps. However, in some cases in which the dorsal digital networks cannot be used, cross-finger flaps are still indicated for cover of long fingers beyond the PIP joint. The authors present a new flap eliminating the need for this rather complicated procedure. The donor site takes advantage of the rich dorsal collateral arterial network of P1 of an adjacent healthy finger. The flap can be raised due to the constant existence of a bifurcation between the collateral dorsal digital arterial networks and the anastomoses situated at various levels between the dorsal and palmar collateral networks of the long fingers, which are constant as far as the PIP joint. A dorsolateral flap can therefore be raised from a healthy finger and transferred to the injured finger by raising the fatty connective tissue, including the dorsal collateral pedicles, in the shape of a boomerang. This flap covers distal defects from the PIP joint to the fingertip. The authors describe the anatomical basis for raising of the flap, the operative technique and report six clinical cases with a mean follow-up of 11 months.

Arteries↗