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[Application of Internet technology in public health].
Recent advances in telecommunication technology have been enormous. Application of this technology in public health has the potential to markedly improve global health through better surveillance and information systems. With this assumption the GHNet was established in 1994 by representatives from academia, WHO, Pan American Health Organization, the World Bank, NASA, IBM, and AT & T. The GHNet consists of seven components: 1) promotion of networking with the Internet among people in public health; 2) disease tele-monitoring; 3) distance learning system with the internet; 4) connection of non-governmental health organizations; 5) training cyberdocs who are educated in both public health and telecommunications; 6) establishment of an electronic scientific research server; and 7) a home page on the World Wide Web (WWW). In order to effectively incorporate the Internet into the field, connectivity and knowing how to use it are of critical concern. More and more facilities are connected to the Internet in Japan. However, few courses teaching how to utilize the Internet are provided for people in this field. An Internet training course for people in public health was held as joint venture of the World Health Organization (WHO) and the Global Health Network (GHNet) on October 31, 1996, at the 55th Annual Meeting of Japanese Society of Public Health. Most of the participants for the course were from local public health departments and very few had previous experience with the Internet before the course. During this course participants learned how to use e-mail, how to find health resources on the WWW, how to construct a home page, and how the Internet could be utilized to improve public health, with their computers actually hooked to the Internet. From this experience, we found that this kind of course is feasible and beneficial and hope that this course would serve as a model for training people in public health.
Telemedicine system using computed tomography van of high-speed telecommunication vehicle.
The current medical system provides medical services to patients who visit hospitals. However, medical services can be provided at or close to the home of the patient using fully equipped mobile telemedicine systems. Such a system can identify the disease at an early stage, improve quality of life and prognosis through early diagnosis and treatment, and reduce the costs of medical service. Furthermore, the unit can provide mass screenings of the population, as well as full medical service to remote areas. The Telecommunications Advanced Organization of Japan, Matsumoto, Japan, and Shinshu University Hospital, Matsumoto, Japan, established a research center for a unique telemedicine project using a mobile system. The mobile unit consists of a van that houses a spiral computed-tomography (CT) machine and various telecommunications equipment. The unit allows medical examination, CT scanning, and on-line two-way transfer of image data/teleconferencing to a medical center for consultation with various specialists. We have used the system thus far for the early detection of lung cancer through mass screenings over a four-year period in 29 administrative districts. Mass screenings of 19117 residents resulted in the identification of 75 cases of early lung cancer who were later treated by partial pneumonectomy at Shinshu University Hospital and affiliated hospitals. We have also used the system to provide medical services to rural areas, as telemedicine support at remote areas, wintertime telemedicine support to an international sports competition, and various medical services to a home-care facility.
Standards for data collection and monitoring in a telemedicine research network.
While a networked, nationwide health information system is financially and logistically impractical, the development of independent, regional systems is realistic and feasible. A Telemedicine Research Network (TRN) could connect a number of geographically disparate health systems. This would require the reconciliation of policies and practices in five principal areas: partner agreement on project scope; privacy, security and confidentiality; technical standards; telecommunications and computer infrastructure; change management and training. Initial establishment of a first-stage TRN would require very little technical development and would, instead, rely on trust among the partners. The development of standards-based TRNs will greatly increase the quality and quantity of telemedicine research.
Receptor-agonist interactions in service-theoretic perspective, effects of molecular timing on the shape of dose-response curves.
Service-theoretic concepts and methods, widely used in other fields (e.g., telecommunication and operations research), are useful also in a biochemical setting because the treatment of biocatalysts (enzymes, receptors) as servers and their ligands as customers, based on the established formal methods of service or queuing theory, may lead to insights and results unobtainable by conventional, mass-action-law-based theories. In this article, we apply the service-theoretic approach to receptor-agonist systems and show how by changing the stochastic time pattern of "operationally relevant" point events (e.g., instants of agonist arrival, instants of post-climax agonist departure) a great variety of dose-response curves may be generated, even in very simple reaction schemes, which, according to mass action kinetics, invariably lead to hyperbolic r(A) curves (r and A stand for response and agonist concentration, respectively). The molecular timing inherent to a hyperbolic response system is not optimal: for instance, at the agonist concentration A(50), half of the agonist molecules are rejected ("lost") because of unfortunate timing of the arrival events. The fraction of lost arrivers can be diminished considerably if the arrivals are better timed: "sub-Poisson" arrivals improve the timing and, thus, convert hyperbolic r(A) curves into "lifted" nonhyperbolic ones. Conversely, "super-Poisson" arrivals make the non-optimal timing in hyperbolic response systems even worse and, thus, convert hyperbolic r(A) curves into "depressed" nonhyperbolic ones. Furthermore, under special timing conditions, nonhyperbolic r(A) curves can be generated, which are partly lifted, partly depressed relative to the reference hyperbola, and which resemble in shape well-known nonhyperbolic forms of enzyme and receptor kinetics (negatively cooperative, positively cooperative, and sigmoidal kinetics). In addition unusual (undulatory and sawtooth-like) r(A) curves can be generated solely by changing the temporal pattern of arrival and service completion instants. Virtually any shape of dose-response curves may be obtained by allowing for probability distributions whose characteristic shape varies with their mean; we call such distributions "variomorphic" and apply them to the arrival process of agonist molecules.
The computer in the radiologist's office.
Today, the radiologist is able to equip his or her office with a powerful personal computer system equivalent to the large mainframe computers of just a few years ago. If funds permit, purchase of a 486 equivalent system with 200-300 Mbytes of hard-disk storage, 16 Mbytes of random access memory (RAM), a high-resolution color video card and monitor, and a laser printer is recommended. The practical uses for such a system are almost limitless and include word processing, spreadsheet and data-base management, telecommunications, multimedia presentations, business applications, teleradiology, resident and medical student education, and research applications. No matter how much one becomes involved in computer applications, it is essential to establish good habits for backing up critical data files and programs. Becoming familiar with computer technology is not easy at first. Finding a good computer buddy, taking simple night school courses, and reading computer articles and magazines are good ways to get started. Computers are wonderful devices. The day is fast approaching when they will become a necessary tool for every radiologist.
Bioengineering and spinal cord injury: a perspective on the state of the science.
There is little doubt that as technologic advances become available, people with spinal cord injuries (SCIs) are living healthier, more productive, and longer lives. Federally and privately funded research, foreign competition, and globalization appear to be factors that will drive bioengineering advances within the assistive technology (AT) industry. The seeds of bioengineering research are likely to contribute to improvements in universal design and the mainstreaming of products. The aims of AT have changed tremendously in the past 50 years. Most of the federal agencies supporting assistive and rehabilitative technology research and development did not exist 50 years ago. Indeed, the leading AT companies all were established within the past 50 years. Bioengineering has the potential to be to the 21 st century what electronic engineering was to the 20th century. Advances in power electronics, telecommunications, controls, sensors, and instrumentation have really only just begun to be applied for devices to assist people with SCI. Advancing technology for people with SCI represents a significant career and business opportunity for engineers who want to serve the public good in a meaningful and tangible way.
[Evidence-based medicine].
The growing array of diagnostic and therapeutic options available to the clinician has created the necessity of techniques, such as the randomized clinical trial, to evaluate their effectiveness. Recently, with the increasing penetration of the methods of clinical epidemiology into medical practice, the concept of an evidence-based medicine has arisen. Emphasizing the necessity of solid clinical evidence for clinical decision-making, evidence-based medicine provides a framework for the integration of research results into clinical practice. The evidence is graded, principally on the basis of study design, and norms are established as to what constitutes adequate evidence for clinical decision-making. The combination of this new paradigm of medical practice with the power of modern telecommunications is causing a revolution in the way medicine is practiced. Its integration into clinical practice is being facilitated by quantitative overviews of the literature, and the creation of clinical guidelines based on these reviews. Shortcomings of the traditional sources of evidence have been documented. New sources of evidence, such as the ACP Journal Club, and the Cochrane Collaboration, diminish dramatically the time required of clinicians to obtain the best available evidence. All health professionals should familiarize themselves with evidence-based medicine.
The availability of health information in South Africa.
The South African Medical Research Council (MRC) has provided access to on-line health and biomedical information since 1976, when the MRC became an international partner of NLM. This was done to support research and health care when the Institute of Biomedical Communication was established. The institute has since reorganized and is now the Information Systems Division in the Research Systems Support Group MRC. he MRC and medical libraries in South Africa are able to access various automated services via telecommunication. The major systems available are MEDLARS, DIALOG, DATASTAR and BRS, with ECRI being the latest addition; most used are MEDLARS and DIALOG. New technologies (e.g., CD-ROM) have given more people access. This technology is not available to many people working in Primary Health Care (PHC), as they do not have access to computer networks. Beyond on-line is statistical and printed information, called "Gray Literature," not accessible through on-line systems as it is not published in conventional sources used to build databases. With a shift to Essential National Health Research and the focus on PHC and preventative medicine, demand for health information and "gray literature" is growing. The MRC collects and produces this material and has its own database called SAMED, which is to be made available to others as our contribution to health. It is hoped to make this available for inclusion in the proposed African Index Medicus presently investigated by the World Health Organization. Africa as a continent, and South Africa as a country, are experiencing major changes in health care and medical practice, and inevitably, provision of health information services. With South Africa's re-entry into the global village and its acceptance by the rest of Africa, it can be a key player in information provision to the rest of the continent. The MRC, as a major provider of Health information, can play a vital role in the information flow throughout Africa by continuously improving and expanding its services. A large proportion of South Africans live in rural areas where health care is provided by clinics not linked to information networks. This does not mean these clinics are excluded from the use of information. The major challenge is to find the ways and means of getting the relevant information to these clinics. Information is needed to help with patient care and continuing education. With this in mind, the MRC is evaluating different formats in which information can be supplied. Due to the lack of computer literacy, facilities, and financial constraints, it is better to supply printed information. With the spread of technology through the country and continent, it can be assumed that information flow and transfer will be more rapid. Repackaging of information means that it is possible to get the relevant information to the right people at the right time. The first such package developed is for hospital managers. With the help from experts in the field of PHC, it is hoped to develop packages aimed specifically at the CHWs and other workers in the field. All packages developed by the MRC are backed by a document provision service, using the most cost-effective route to obtain documents. A printed product must comply with certain criteria; these are: 1) purpose for which the information is needed; 2) kind of information needed and the format in which it is needed; 3) when the information is needed; 4) is the information to be supplied on an ongoing basis i.e., updated with latest information; 5) cost involved; and 6) how to get the information to the relevant user.
Organization and activities of the International Radio Medical Centre (CIRM).
The International Radio Medical Centre (CIRM) was founded in 1935, to provide free medical assistance by radio to ships with no doctor on board and others who cannot be reached by a doctor. In 1950 CIRM was established as a non-profit-making foundation and has benefited since 1957 from an annual contribution from the Italian government. The results achieved by the Centre over 61 years include medical assistance to 42,935 patients on board ships (as well as on small islands and aircraft), with 375,264 medical messages received and transmitted. CIRM is organized into a medical service, a telecommunications service and a studies section. The 24-h continuous medical service is provided by doctors at the CIRM headquarters. The doctor on duty gives instructions for managing the case. If necessary the medical service will coordinate the patient's hospitalization at the nearest port with suitable medical facilities or arrange the patient's transfer to another ship with a doctor on board, or an airlift. The telecommunications service receives requests for assistance, locates the ship or whoever made the request, passes the call to the doctor on duty, and relays the doctor's response to those requesting assistance. The studies section, established in 1957-58, researches occupational pathologies of sailors and contributes to their prevention. This provides a scientific basis for improving medical assistance to sailors at sea.
Health risks from the use of mobile phones.
Widespread concerns have been raised about the possibility that exposure to the radiofrequency (RF) fields from mobile telephones or their base stations could affect people's health. Such has been the rapid growth of mobile telecommunications that there will be about one billion mobile phone users before 2005. Already there are more mobile than fixed-line users. Developing countries are establishing mobile telecommunications rather than the more expensive fixed-line systems. Thus, if there is any impact on health from mobile telephones, it will affect everyone in the world. The World Health Organization (WHO) established the International EMF Project in 1996 to evaluate the science, recommend research to fill any gaps in knowledge and to conduct formal health risk assessments of RF exposure once recommended research had been completed. In addition, the UK government established an independent expert group to review all the issues concerning health effects of mobile telephones and siting of base stations. Cancer has been suggested as an outcome of exposure to mobile telephones by some scientific reports. This paper reviews the status of the science and WHO's programme to address the key issues. In addition, the main conclusions and recommendations of the UK expert group will be summarised.
High quality image oriented telemedicine with multimedia technology.
Researchers at Osaka and Kyoto University hospital performed three experiments, beginning in 1995, which looked at high quality-oriented telemedicine. This paper describes the system design for the three projects. Experiment 1 applied high-definition TV images and B-ISDN for distance learning and medical information exchange. Experiment 2 developed a super high-definition medical image filing system and the images were transmitted via B-ISDN for teleconferences and experiment 3 utilized digital, high-definition, TV images and communication satellites for teleconferences. Multimedia and communication technologies were considered to be fundamental components of telemedicine. The three projects were evaluated initially for quality of images, operability and utility. The experimental design and its implementation showed that it was possible to provide high quality image-oriented telemedicine in the health care environment. Obstacles to establishing practical telemedicine are also discussed.
Maternity care in the bush: using the Internet to provide educational resources to isolated practitioners.
INTRODUCTION: Telecommunication infrastructure is being rolled out across Australia with little knowledge about the uptake by health professionals in remote areas. Computer mediated communication has the potential to offer educational support to remote practitioners; however, the viability of this is uncertain. The aim of this research was to establish and evaluate an internet-based resource library targeting the needs of remote area maternity service providers. METHODS: A participatory action research (PAR) approach was used to involve remote area maternity service providers in the Northern Territory of Australia. The evaluation of the resource library included its performance on reach, agency affiliation and richness, factors identified to affect the sustainability and utility of such a resource. An additional component of the evaluation framework documented the facilitators of and barriers to using an information technology strategy to reduce the isolation of remote area maternity service providers. RESULTS: Overall, the evaluation of the resource library was very positive. Feedback from the PAR team described the resource as contemporary, useful and relevant. Practitioners in leadership and education positions identified the resource library as a valuable tool that enabled them to access professional knowledge, which could then be distributed to any remote-based practitioners, who experienced difficulties with access themselves. The evaluation found that logistical issues were a major problem for potential users. Hardware inadequacies, access difficulties, unfamiliarity with computers, and a lack of management support for nursing and midwifery staff to utilise the resource, were all identified barriers. Remote-area practitioners highlighted education, training and 24 hour support as key priorities. CONCLUSIONS: Results from this research clearly showed the potential of web-based resources to offer educational support through access to clinical guidelines, reports and research, thus reducing the isolation of the remote practitioner. However, it highlighted the need for clear strategic direction at policy level, whereby all stakeholders unite to synchronise the rollout of information technology infrastructure with the necessary education, training and support as an integral component.
Telemedicine versus face to face patient care: effects on professional practice and health care outcomes.
BACKGROUND: Telemedicine is the use of telecommunications technology for medical diagnosis and patient care. From its beginnings telemedicine has been used in a variety of health care fields, although widespread interest among healthcare providers has only now become apparent with the development of more sophisticated technology. OBJECTIVES: To assess the effects of telemedicine as an alternative to face-to-face patient care. SEARCH STRATEGY: We searched the Effective Practice and Organisation of Care Group's specialised register, The Cochrane Library, MEDLINE (1966-August 1999), EMBASE (to 1996), Cinahl (to August 1999), Inspec (to August 1996), Healthstar (1983-1996), OCLC, Sigle (to 1999), Assia, SCI (1981-1997), SSCI (1981-1997), DHSS-Data. We hand searched the Journal of Telemedicine and Telecare (1995-1999), Telemedicine Journal (1995-1999) and reference lists of articles. We also hand searched conference proceedings and contacted experts in countries identified as having an interest in telemedicine. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series comparing telemedicine with face-to-face patient care. The participants were qualified health professionals and patients receiving care through telemedicine. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Seven trials involving more than 800 people were included. One trial was concerned with telemedicine in the emergency department, one with video-consultations between primary health care and the hospital outpatients department, and the remainder were concerned with the provision of home care or patient self-monitoring of chronic disease. The studies appeared to be well conducted, although patient numbers were small in all but one. Although none of the studies showed any detrimental effects from the interventions, neither did they show unequivocal benefits and the findings did not constitute evidence of the safety of telemedicine. None of the studies included formal economic analysis. All the technological aspects of the interventions appear to have been reliable, and to have been well accepted by patients. REVIEWER'S CONCLUSIONS: Establishing systems for patient care using telecommunications technologies is feasible, but there is little evidence of clinical benefits. The studies provided variable and inconclusive results for other outcomes such as psychological measures, and no analysable data about the cost effectiveness of telemedicine systems. The review demonstrates the need for further research and the fact that it is feasible to carry out randomised trials of telemedicine applications. Policy makers should be cautious about recommending increased use and investment in unevaluated technologies.
Information systems: the key to evidence-based health practice.
Increasing prominence is being given to the use of best current evidence in clinical practice and health services and programme management decision-making. The role of information in evidence-based practice (EBP) is discussed, together with questions of how advanced information systems and technology (IS&T) can contribute to the establishment of a broader perspective for EBP. The author examines the development, validation and use of a variety of sources of evidence and knowledge that go beyond the well-established paradigm of research, clinical trials, and systematic literature review. Opportunities and challenges in the implementation and use of IS&T and knowledge management tools are examined for six application areas: reference databases, contextual data, clinical data repositories, administrative data repositories, decision support software, and Internet-based interactive health information and communication. Computerized and telecommunications applications that support EBP follow a hierarchy in which systems, tasks and complexity range from reference retrieval and the processing of relatively routine transactions, to complex "data mining" and rule-driven decision support systems.
Dynamic algorithms for the shortest path routing problem: learning automata-based solutions.
This paper presents the first Learning Automaton-based solution to the dynamic single source shortest path problem. It involves finding the shortest path in a single-source stochastic graph topology where there are continuous probabilistic updates in the edge-weights. The algorithm is significantly more efficient than the existing solutions, and can be used to find the "statistical" shortest path tree in the "average" graph topology. It converges to this solution irrespective of whether there are new changes in edge-weights taking place or not. In such random settings, the proposed learning automata solution converges to the set of shortest paths. On the other hand, the existing algorithms will fail to exhibit such a behavior, and would recalculate the affected shortest paths after each weight-change. The important contribution of the proposed algorithm is that all the edges in a stochastic graph are not probed, and even if they are, they are not all probed equally often. Indeed, the algorithm attempts to almost always probe only those edges that will be included in the shortest path graph, while probing the other edges minimally. This increases the performance of the proposed algorithm. All the algorithms were tested in environments where edge-weights change stochastically, and where the graph topologies undergo multiple simultaneous edge-weight updates. Its superiority in terms of the average number of processed nodes, scanned edges and the time per update operation, when compared with the existing algorithms, was experimentally established. The algorithm can be applicable in domains ranging from ground transportation to aerospace, from civilian applications to military, from spatial database applications to telecommunications networking.
Developing benchmark inventories to assess the content of telephone consultations in accident and emergency departments: use of the Delphi technique.
The provision of telephone advice to members of the general public from staff based in accident and emergency departments is common practice. However, it is largely conducted on an ad hoc basis without the use of formal guidelines or decision support. The evidence base from which to derive guidelines for the telephone assessment and advice of many common conditions is lacking. This study, using the Delphi technique, was undertaken to develop a number of benchmarks for use as objective measures against which the comprehensiveness of telephone assessments could be tested. Consensus views on the essential and desirable items to be considered for each of 10 presenting complaints was achieved. It is argued that establishing consensus views on clinical topics provides an effective means of developing an evidence base where other sources of evidence are lacking.
Teleradiology: meeting the challenge of the '90s.
Despite spectacular scientific advance and contributions to patient care, radiology stands at a frightening crossroads in its 100-year history. Economic and political changes endanger the fundamental principles of patient care, research, and teaching and threaten to dismantle the subspecialized expertise that characterizes our great academic medical institutions. In response, we should be creative and find new ways to exploit this expertise in an effort to maintain clinical and research excellence. Teleradiology can be used to improve the quality and decrease the cost of medical care at home and abroad--meeting the challenge of the 1990's. Teleradiology and other telemedical applications can benefit from the nation's investment in telecommunications infrastructure. The enabling technologies to provide teleradiology services are available and the feasibility of performing primary interpretations has been established. We offer our experience and plans as a model for diversifying and strengthening the academic radiology department of the future.