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Experience with telepathology in combination with diagnostic assistance systems in countries with restricted resources
Abstract
Introduction:
We describe the use of telepathology in countries with restricted resources using two diagnosis assistance systems (Isabel and Memem7) in addition to the diagnoses made by experts in pathology via the iPath-Network.
Methods:
A total of 156 cases, largely from Afghanistan, were analysed; 18 cases had to be excluded because of poor image quality.
Results:
Of the remaining 138 cases (100%), a responsible physician provided a tentative diagnosis for 61.6% of them. With a diagnosis from a consultant pathologist, it was then possible to make a definite diagnosis in 84.8% of cases on the basis of images taken from hematoxylin and eosin staining sections alone. The use of the diagnosis assistance systems resulted in an ordered list of differential diagnoses in 82.6% (IsabelHealth) and in 74.6% (Memem7) of cases, respectively. Adding morphological terminology reduced the list of possible diagnoses to 52.2% (72 cases, Memem7), but improved their quality.
Discussion:
In summary, diagnosis assistance systems are promising approaches to provide physicians in countries with restricted resources with lists of probable differential diagnoses, thus increasing the plausibility of the diagnosis of the consultant pathologist.
... 24 articles were included for analysis. See Fig. 2. PRISMA chart (Fig. 2) Included articles were observational studies (10 articles, all case series) [27][28][29][30][31][32][33][34][35][36], commentaries and case reports (8 articles) [37][38][39][40][41][42][43][44], interventional studies (4 articles, randomised control trials and before-after interventions) [45][46][47][48] and cross-sectional studies (2 articles) [49,50] (Fig. 2). Since studies predominantly described implementation rather than effectiveness of interventions, common themes were mapped into a conceptual framework adapted from Damschoder et al. ...
... Telemedicine was represented in ten specialities across conflict settings (Fig. 4) and aimed to alleviate the shortage of specialist healthcare workers. Broadly, three types of telemedicine were used: Specialties only exchanging images and short text accounted for four studies, including transfer of histological slides in tele-pathology [45] and tele-dermatopathology [46] interventions from Afghanistan. Additionally, Digital Imaging and Communications in Medicine (DICOM) transmission of radiological images in tele-radiology interventions from Iraq [30] and Syria [29]. ...
... When recruiting local providers, some telemedicine facilitators identified suitable providers by enlisting local partners [27,28,33,38,39,46], while in other studies, local providers approached facilitators instead [35,40,41,45]. Four Syria-based studies gained local partners through other humanitarian activities of the facilitators [29,31,33,38], and two studies utilised academic collaborations with universities in Iraq and Afghanistan [28,46]. ...
Background
The COVID-19 pandemic has escalated the use of telemedicine in both high and low resource settings however its use has preceded this, particularly in conflict-affected settings. Several countries in the WHO Eastern Mediterranean (EMR) region are affected by complex, protracted crises. Though telemedicine has been used in such settings, there has been no comprehensive assessment of what interventions are used, their efficacy, barriers, or current research gaps.
Main body
A systematic search of ten academic databases and 3 grey literature sources from January 1st 2000 to December 31st 2020 was completed, identifying telemedicine interventions in select EMR conflict-affected settings and relevant enablers and barriers to their implementation. Included articles reported on telemedicine use in six conflict-affected EMR countries (or territories) graded as WHO Health Emergencies: Afghanistan, Gaza, Iraq, Libya, Syria and Yemen. Data were extracted and narratively synthesised due to heterogeneity in study design and outcomes. Of 3419 articles identified, twenty-one peer-reviewed and three grey literature sources met the inclusion criteria. We analysed these by context, intervention, and evaluation. Context: eight related to Afghanistan, eight to Syria and seven to Iraq with one each in Yemen and Gaza. Most were implemented by humanitarian or academic organisations with projects mostly initiated in the United States or Europe and mostly by physicians. The in-country links were mostly health professionals rather than patients seeking specialist inputs for specialities not locally available. Interventions: these included both SAF (store and forward) and RT (real-time) with a range of specialities represented including radiology, histopathology, dermatology, mental health, and intensive care. Evaluation: most papers were observational or descriptive with few describing quality measures of interventions.
Conclusions
Telemedicine interventions are feasible in conflict-affected settings in EMR using low-cost, accessible technologies. However, few implemented interventions reported on evaluation strategies or had these built in. The ad hoc nature of some of the interventions, which relied on volunteers without sustained financial or academic investment, could pose challenges to quality and sustainability. There was little exploration of confidentiality, ethical standards, data storage or local healthcare worker and patient acceptability.
... At its core, telepathology requires a digital camera system to capture the image and an infrastructure to distribute and visualize the images afar [11]. Not only can telepathology facilitate the primary diagnosis of samples, but also improve the teaching of junior pathologists by more experienced staff, as well as in basic research, student education, and remote consultations [12][13][14][15]. ...
... Cost is a significant hurdle when establishing a telepathology system, especially in a limited-resource setting, where they are needed the most [14,16,17]. A telepathology system based on WSI requires an initial high investment to acquire slide scanners, followed by substantial running costs, including service, data storage, internet bandwidth, and computer infrastructure. ...
Telepathology facilitates histological diagnoses through sharing expertise between pathologists. However, the associated costs are high and frequently prohibitive, especially in low-resource settings, where telepathology would paradoxically be of paramount importance due to a paucity of pathologists.
We have constructed a telepathology system (TelePi) with a budget of < €120 using the small, single-board computer Raspberry Pi Zero and its High-Quality Camera Module in conjunction with a standard microscope and open-source software. The system requires no maintenance costs or service contracts, has a small footprint, can be moved and shared across several microscopes, and is independent from other computer operating systems. TelePi uses a responsive and high-resolution web-based live stream which allows remote consultation between two or more locations. TelePi can serve as a telepathology system for remote diagnostics of frozen sections. Additionally, it can be used as a standard microscope camera for teaching of medical students and for basic research. The quality of the TelePi system compared favorable to a commercially available telepathology system that exceed its cost by more than 125-fold. Additionally, still images are of publication quality equal to that of a whole slide scanner that costs 800 times more.
In summary, TelePi is an affordable, versatile, and inexpensive camera system that potentially enables telepathology in low-resource settings without sacrificing image quality.
... (2) The two image recognition methods did not differ significantly in their test performance (Table 2 and 3). (3) The performance of the context variables is consistent with the findings of a previous work [37] and has a better test performance compared to the two image recognition methods. ...
Purpose: Since 2010, physicians from Afghanistan have been uploading images of histological and cytological specimens to a telemedicine internet platform (iPath network) for expert evaluation. From this collective work, all cases with fine-needle aspirations (FNA) of mammary gland diseases were extracted and analyzed. The aim of the present retrospective feasibility study is to investigate the utility of artificial intelligence assisted diagnoses in fine-needle aspiration (FNA) of breast diseases.Material and Methods: A total of 3304 microphotographic images from 438 patients of smears from FNA of the mammary gland were available for this study. Telemedical expert diagnoses from 4 experienced cytopathologists were available in all 438 cases. Their diagnosis (malignant tumor of the mammary gland or benign mammary gland disease) was set as the gold standard. AI analysis was performed using i) clinical context data and ii) two different image recognition methods to determine the probability values for the presence of malignant breast tumor. Youden index and AUC (area under the curve) were used to evaluate test performance. Results: A score for invasive breast cancer (IBC) calculated from contextual variables agreed with the expert diagnosis (accuracy) in 85.2% and with the two image recognition systems in 78.4% and 65.2%. This simplifies health healthcare management of breast diseases in low income countries as in many patients the less expensive and less time-consuming technique of FNA may replace a histological examination.Conclusion: Image classification and analysis of context variables can be used to test the validity and plausibility of cytologic diagnoses, especially when cytologic interpretation has to be performed by people who are inexperienced in cytopathology.
... Memem7 [22][23][24]: Is a currently non-commercial DDX developed by two of the authors (KA, PF). Memem7 is based on a large semantic network (about 560,000 nodes) that is transparently represented to the user, containing all kinds of entities and relationships such as objects, classes, parts, attributes, processes, states, properties, etc. ...
Background
Medical decision support systems (CDSSs) are increasingly used in medicine, but their utility in daily medical practice is difficult to evaluate. One variant of CDSS is a generator of differential diagnoses (DDx generator). We performed a feasibility study on three different, publicly available data sets of medical cases in order to identify the frequency in which two different DDx generators provide helpful information (either by providing a list of differential diagnosis or recognizing the expert diagnosis if available) for a given case report.
Methods
Used data sets were n = 105 cases from a web-based forum of telemedicine with real life cases from Afghanistan (Afghan data set; AD), n = 124 cases discussed in a web-based medical forum (Coliquio data set; CD). Both websites are restricted for medical professionals only. The third data set consisted 50 special case reports published in the New England Journal of Medicine (NEJM). After keyword extraction, data were entered into two different DDx generators (IsabelHealth (IH), Memem7 (M7)) to examine differences in target diagnosis recognition and physician-rated usefulness between DDx generators.
Results
Both DDx generators detected the target diagnosis equally successfully (all cases: M7, 83/170 (49%); IH 90/170 (53%), NEJM: M7, 28/50 (56%); IH, 34/50 (68%); differences n.s.). Differences occurred in AD, where detection of an expert diagnosis was less successful with IH than with M7 (29.7% vs. 54.1%, p = 0.003). In contrast, in CD IH performed significantly better than M7 (73.9% vs. 32.6%, p = 0.021). Congruent identification of target diagnosis occurred in only 46/170 (27.1%) of cases. However, a qualitative analysis of the DDx results revealed useful complements from using the two systems in parallel.
Conclusion
Both DDx systems IsabelHealth and Memem7 provided substantial help in finding a helpful list of differential diagnoses or identifying the target diagnosis either in standard cases or complicated and rare cases. Our pilot study highlights the need for different levels of complexity and types of real-world medical test cases, as there are significant differences between DDx generators away from traditional case reports. Combining different results from DDx generators seems to be a possible approach for future review and use of the systems.
... AI has shown excellent performance in image recognition tasks and has been widely studied in breast cancer screening [9].There is no doubt that surgery, chemo, and radiotherapy will remain the standard cancer therapy for many years to come, but at the same time, there is mounting interest from the scientific community to further mature the current clinical strategies to deal with cancer. The involvement of computational input and assistance will be a tangible reality for the future clinical setting and will produce a significant technological revolution to predict and diagnose human health-related issues in real-time.AI avoids emotional problems, cultural and moral beliefs, and fatigue [13], [14], [15]. ...
Breast cancer is the second most common cancer in women after skin cancer. When cancer care is delayed or inaccessible, there is a lower chance of survival, greater problems associated with treatment and higher costs of care. Early diagnosis improves cancer outcomes and leads to a better prognosis. In third world countries like Nigeria, where state-of-the art breast cancer diagnostic machines and the experts are grossly insufficient, alternative approaches to early diagnosis of breast cancer must be evolved. These preliminary data obtained from images of suspected cases of breast cancer are transformed in profiles of breast diseases, which are used by the local physicians in charge of breast disease patients. Each new case can then be compared by the local treating physician with the profile of all preceded cases with the same diagnosis. Three supervised learning models; Logistic Regression. Random Forest Classifier, and K-Nearest Neighbors were used to train the cancer dataset, and Random Forest Classifier outperformed with accuracy of 96% and an almost perfect sensitivity/Recall index. The dataset could not capture the demographic effects of the breast cancer images on the diagnosis, which now opens up new research areas in this study of breast cancer.
... These departments have been linked to a third centre in Herat, managed by another NGO, which serves about 2 million people. These three departments regularly send digitized microscopic images of histological and cytological preparations and the related clinical information of the patients to European experts via the telemedicine service iPath-Network [12][13][14]. Up to now, more than 14,500 cases have been diagnosed or confirmed. ...
Background:
This study was performed in knowledge of the increasing gap between breast disease treatment in countries with restricted resources and developed countries with increasingly sophisticated examination methods.
Methods:
The authors present the analysis of a breast disease register consisting of diagnostic cases from Mazar e Sharif and Herat in 2018 and 2019. The study comprises a total of 567 cases, which were presented to experts via telemedicine for final diagnosis. 62 cases (10.9%) were excluded due to inacceptable data or insufficient image quality. These data provided by daily diagnostic classification were used for the built-up of a profile for each frequent breast disease and a breast cancer register. All images and cases were seen by at least 3 independent experts. The diagnoses were made in 60% of cases by cytology of fine needle aspiration and in 40% by histological images.
Results:
For each entity of breast diseases (e.g., fibroadenoma), a profile of context variables was constructed allowing to assist medical decisions, as "wait and see," elective surgery or immediate surgical intervention with R0 (complete) resection. These "profiles" could be described for fibroadenoma, mastitis, galactocele, fibrous-cystic disease, and invasive breast cancer.
Conclusions:
The presented preliminary data set could serve as a cost-effective basis for a North Afghan breast cancer registry, with option to extent to a national model. These preliminary data are transformed in profiles of breast diseases, which are used by the local physicians in charge of breast disease patients. Each new case can be compared by the local treating physician with the profile of all preceded cases with the same diagnosis.
... Identification of countries and conflict has been elicited where possible in the results. The true number of conflict sites and programmes (Ghbeis et al., 2018) MSF clinical decision-making tool (Delaigue et al., 2018) MSF teleneurology service-DRC, Middle East (Saadi and Mateen, 2017) SAMS ITU, Pulmonary and Sleep Medicine Programme, Syria Telecardiology, Syria (Alrifai et al., 2018) Telepsychiatry in Syrian conflict (Jefee-Bahloul, 2014) IPath telepathology, Afghanistan (Fritz et al., 2020) Teledermatology, Afghanistan (Ismail et al., 2018) Global telemental health-Syrian case study (Jefee-Bahloul et al., 2016) a Telehealth solutions for improving mental health, Afghanistan (Khoja et al., 2016) a eHealth for young adult mental healthcare, Badakshan (Gillis, 2015) Telemedicine, Middle East hospitals (Patterson et al., 2007) MSF Teleconsultation MDR-TB, the DRC (Shanks et al., 2012) Telemedicine childrens' hospital, Chechnya (Ehrlich et al., 2007) Teleconsultations, Somalia (Zachariah et al., 2012) Telemedicine, Somalia (Maalim et al., 2014) PASSPORT telepsychiatry, Syria Teleintensive care, Syria (Moughrabieh and Weinert, 2016) Telepsychiatry for PTSD, Syria (Nassan et al., 2015) Teleconsultation cancer care, Syria (Sahloul et al., 2017) MSF Humanitarian Telemedicine Service Inc. CAR, South Sudan (Walji, 2015) Telemedicine, South Sudan (Joseph, 2013) eHealth in primary care, Lebanon (Saleh et al. 2018a) M-Health for NCDs in refugee camps (Saleh et al., 2018b) a Intervention spanning more than one category. deployed may therefore be larger than that described due to vague reporting in the published literature. ...
The role of eHealth in conflict settings is increasingly important to address geographic, epidemiologic and clinical disparities. This study categorizes various forms of eHealth usage in conflict and aims to identify gaps in evidence to make recommendations for further research and practice. The analysis was carried out via a narrative hermeneutic review methodology. Articles that fulfilled the following screening criteria were reviewed: (1) describing an eHealth intervention in active conflict or ongoing insurgency, (2) an eHealth intervention targeting a conflict-affected population, (3) an e-learning platform for delivery in conflict settings and (4) non-interventional descriptive reviews relating to eHealth in conflict. Of the 489 papers eligible for screening, 46 merited final inclusion. Conflict settings described include Somalia, Sudan, Afghanistan, Syria, Iraq, Pakistan, Chechnya, Gaza and the Democratic Republic of Congo. Thirty-six studies described specific eHealth initiatives, while the remainder were more generic review papers exploring general principles. Analysis resulted in the elucidation of three final categories of current eHealth activity in conflict-affected settings: (1) eHealth for clinical management, (2) e-learning for healthcare in conflict and (3) eHealth for information management in conflict. Obvious disparities in the distribution of technological dividends from eHealth in conflict are demonstrated by this review. Conflict-affected populations are predominantly subject to ad hoc and voluntary initiatives delivered by diaspora and civil society organizations. While the deployment of eHealth technologies in conflict settings is increasingly normalized, there is a need for further clarification of global norms relating to practice in this context.
Afghanistan is in the midst of more than 22 years of violent conflicts and according to recent political development, in a downward spiral towards a disintegrated society, that seems to have abandoned any hope for political sanity. This scenario faces the question of the usefulness of international medical aid, especially morphological diagnostics in crisis situations. On the basis of ten years of experience with a telemedicine project in Afghanistan, the necessity, feasibility and results as well as the future viability even under a new government are discussed. General and country-specific problems and the sustainability of an international partnership are discussed. In summary our experiences are: (1) Telemedicine is possible and necessary even in countries with high conflict potential. It is integrated into routine care by local physicians, (2) Accompanying video conferences are a significant improvement in telemedical diagnostics, (3) “High level” consultations can bridge the gap between sophisticated Western diagnostics and medicine in the partner country in selected cases and (4) Scientific work is possible on the basis of medical data collected on site and the image material generated.
Afghanistan is in a military conflict lasting more than 20 years and according to recent political development, in a downhill spiral towards a failed society. This scenario faces the question of the usefulness of international medical aid, especially morphological diagnostics in crisis situations. On the basis of ten years of experience from a telemedicine project, need, feasibility and results in Afghanistan will be discussed. General and country-specific problems and the sustainability of an international partnership are discussed. In summary our experience is: (1) Telemedicine is possible and necessary even in countries with high conflict potential. It is integrated into routine care by local medical care taker, (2) Accompanying video conferences are a significant improvement in telemedical diagnostics, (3) "High level" consultations can bridge the gap between sophisticated western diagnostics and medicine in the partner country in selected cases and (4) Scientific work is possible on the basis of the medical data collected on site and the image material generated.
Digital technology has the potential of reshaping both clinical medicine and medical research. In pathology, the increasingly widespread adoption of whole slide imaging (WSI) technology has fueled this transition. The benefits are obvious in such matters as education, peer review, archival retrieval, intra- and extrainstitutional consultation, and ultimately primary diagnosis in most aspects of diagnostic anatomic pathology. Of equal importance is the use of WSI to assist in both the integration of advanced state-of-the-art imaging methodologies and the use of deep learning strategies to inform both diagnostic and therapeutic decision-making. For all of these, important issues relating to standardization, validation, and implementation must be addressed to maximize gains in information, management, image sharing, and image analysis/interpretation.
Static telepathology is one of the telepathology methods, in which the captured images of the slides are transmitted for consultation at a later time. This study aimed to compare the diagnostic accuracy of the conventional pathology and static telepathology systems. Eighty-two cases that had been selected randomly from 4 pathology centers in the city of Kerman were diagnosed by a pathologist, first based on light microscopy and then after 2 months based on static images (2 images per case) captured by a Nikon 50i microscopic camera. The images were sent to the pathologist via e-mail. The diagnostic accuracy of the telepathology system was calculated. The light microscopic diagnoses were concordant with the telepathologic diagnoses in 71 of 82 reviewed cases. Different diagnoses of 7 cases were due to the images captured from the inappropriate location of the slides. The diagnostic accuracy of the telepathology system was 86.5%. The results of this study showed that static telepathology is very accurate and can be widely used in Iran. However, efficient implementation and use of telepathology require paying attention to different issues such as educational, legal, ethical, financial, and security and observance of the standards related to this field.
Background
The variety and complexity of dermatologic diseases in Afghanistan and the associated diagnostic resource constraints have not been previously studied. Moreover, the utility of store-and-forward teledermatopathology in this resource-limited setting has not been investigated.
Methods
A retrospective analysis was conducted of 150 store-and-forward teledermatopathology cases that were composed of a clinical history, clinical images, and histologic images that were sent from an academic teaching hospital in Kabul to a dermatology-trained dermatopathologist at Emory University in the United States between November 2013 and June 2017. For each case, the histologic impression of the Emory dermatopathologist was compared with that of the Kabul-based general pathologist and the clinical differential diagnosis and histologic impression of the Kabul-based dermatologist.
Results
Eighty-one of the cases that were analyzed were from female patients. The diagnosis after telepathology consultation differed from the first entity in the clinical differential diagnosis in 34.7% of cases. The telepathology consultation refined the Afghan general pathologist’s histologic impression 45.5% of the time and the Kabul-based dermatologist’s histologic impression 24.3% of the time. A clinically significant difference in care was made in 19.3% of cases for which an analysis could take place between the histologic impressions of the Emory dermatopathologist and U.S.-trained dermatologist. The most common resource constraints that limited a definitive diagnosis were the inability to perform infectious stains and cultures to identify specific pathogens (19.3% of cases) and immunofluorescence studies to confirm autoimmune bullous disease (6.7% of cases).
Conclusions
These results highlight the important diagnostic role that teledermatopathology can serve in resource-limited settings such as in Afghanistan.
Background:
In the year 2014, Android smartphones accounted for one-third of mobile connections globally but are predicted to increase to two-thirds by 2020. In developing countries, where teleconsultations can benefit health-care providers most, the ratio is even higher. This study compared the use of two Android phones, an 8 megapixel (MP) and a 16 MP phone, for capturing microscopic images.
Method:
The Android phones were used to capture images and videos of a gastrointestinal biopsy teaching set of referred cases from the Armed Forces Institute of Pathology (AFIP). The acquired images and videos were reviewed online by two pathologists for image quality, adequacy for diagnosis, usefulness of video overviews, and confidence in diagnosis, on a 5-point Likert scale.
Results:
The results show higher means in a 5-point Likert scale for the 8 MP versus the 16 MP phone that were statistically significant in adequacy of images (4.0 vs. 3.75) for rendering diagnosis and for agreement with the reference diagnosis (2.33 vs. 2.07). Although the quality of images was found higher in the 16 MP phone (3.8 vs. 3.65), these were not statistically significant. Adding video images of the entire specimen was found to be useful for evaluating the slides (combined mean, 4.0).
Conclusion:
For telepathology and other image dependent practices in developing countries, Android phones could be a useful tool for capturing images.
Objective: The purpose of this study was to assess the current status and future trends in telepathology (TP) and digital pathology (DP) in central India.
Materials and Methods: A self-constructed questionnaire including 12 questions was designed with five specialists, to improve the design ambiguity. The study was conducted through postal and online survey consisting of 12 questions and sent to 300 histopathologists.
Results: A total of 247 histopathologists answered the survey. The overall response rate was 81%. 98% pathologists felt the need for TP and DP. 34% pathologists used digital photomicrographic images in routine practice. Utilization of DP in most efficient way was observed by 48% pathologists mainly for the purpose of teaching in academic institutions. 82% believed that TP is helpful to take an expert opinion whereas only26% believed that a second opinion has to be taken. With respect to limitations, 67% pathologists believed that its cost-effective whereas 51% revealed high use of TP in next 5 years.
Conclusions: Our survey shows that as the field evolves, pathologists are more towards welcoming TP and DP, provided frequent workshops and training programs are conducted. The results of this survey indicates that pathology staff across central India currently utilize gross digital images for educational or academic purposes. They also revealed that technology will be required in near future applications in academics, consultation and for medico-legal purposes.
Telepathology has grown immensely due to rapid advances in information and technology. It has a wide variety of applications especially in the developing world, namely for remote primary diagnosis, specialist referrals, secondary opinions, remote teachings and in research. Basic infrastructure and skilled and experienced staff are the prerequisites for its successful implementation.Socio-economic differences in developing nations result in a chaotic scenario so that, the advanced areas have expertise, while rural and remote areas remain deprived. Telepathology has the potential to bridge this gap.This article discusses how successful use of the internet for telepathology is bridging this gap in developing nations and thereby contributing positively to effective healthcare. Possible constraints to telepathology and some solutions to overcome them are also discussed.
The first appearance of the word "telepathology" in a scientific paper can be tracked down to 1986, in a famous editorial of Ronald Weinstein. Since that paper, research in telepathology grew up developing different subfields, including static and dynamic telepathology and more recently virtual microscopy. The present work attempts an analysis of research in telepathology, starting from the tools provided by bibliometrics.
A query has been developed to extract papers related to telepathology and virtual microscopy, and it has been then submitted to Pubmed by means of Entrez Utilities functions. Results obtained in XML have been processed through ad-hoc developed PHP scripts, in order to extract data on Authors, countries, and keywords.
On PubMed, 967 papers related to telepathology and virtual microscopy have been retrieved, which involved 2904 Authors; corresponding authors were from 37 countries. Of those authors, 2213 co-authored just one paper. Papers were published on 344 different journals, of which only 52 from the Pathology field. An analysis of papers per year has been also attempted, that demonstrates variable research output in time.
From the proposed analysis, telepathology seems to have been consistently studied, in time, by about 400 researchers, with occasional participation of many other people. Telepathology research seems also to have varied in time, although some peaks in paper publishing are certainly related to the proceedings of the European congress on telepathology series, when they have been published on journals. However, some clear sign appears that suggests research in traditional telepathology, after a peak in 2000, showed some decline until virtual microscopy became mainstream, topic that currently pushes research again. The low number of clinical trials calls for more randomized studies in telepathology, to enable evidence-based application.
One of the most promising applications of telepathology (pathology at a distance by electronic transmission of images in pathology) is frozen section diagnosis, especially because by means of this tool operations requiring an intraoperative histopathological diagnosis are feasible at hospitals without a pathologist on‐site. For the introduction of this diagnostic tool into pathologist's daily practice the evidence of its diagnostic accuracy comparable to that of the conventional frozen section diagnosis is crucial.
For this purpose the literature on the diagnostic accuracy of telepathological frozen section diagnosis was reviewed. In a metaanalysis these studies and reports, in which a total of more than 1290 cases had been examined, showed a slightly lower overall diagnostic accuracy (of the telepathological frozen section diagnosis) of about 0.91 than the conventional frozen section diagnosis with an average accuracy of about 0.98 found in an analysis of several studies (on frozen section diagnosis of different organs). This difference is at least predominantly caused by a higher rate of deferred and false negative frozen section diagnoses in the telepathological method, while the specificity of both methods, each more than 0.99 was not significantly different.
In conclusion, the introduction of a telepathological frozen section diagnosis for hospitals without an acceptable access to a pathologist is justifiable already at the current state of the technological development especially when considering the advantages (time saving, reduction in costs) compared to the alternative of surgical interventions without access to an intraoperative diagnosis.
Urinary cytology is limited by high interobserver variability in the evaluation of cells with little atypia. We set up an online quiz on urinary cytology and tested the performance of 246 international participants. The quiz consisted of still images of 42 urinary specimens with equivocal morphologic features and 10 control cases with an unequivocal cytologic diagnosis. The nature of the cells on the 292 quiz images had been verified by multitarget fluorescence in situ hybridization in addition to the information obtained by cystoscopy, clinical follow up, and/or histologic examination. The original quiz cases and the percentage of answers given by the participants can be viewed at: http://kathrin.unibas.ch/urinzyto/. High-grade cancers were diagnosed correctly in 76.0% and low-grade cancers in only 33.9%. Remarkably, 54.5% of all participants misclassified decoy cells as malignant. This study shows that large-scale international online quizzes may be used to find educational deficits in cytopathology.
The paper reviews the development of the application of telepathology in a department of surgical pathology between 1991 and 2003. The goal of the efforts during this time was to give up the concept of programming a single application, available only between two fixed workstations with sophisticated devices and special software, and to find the virtual "largest common denominator" for implementing as many different applications as possible with the same basic system.
A new telepathology system was designed as a client-server system with a relational database at its centre. The clients interact together by transferring the questions (texts and images) to a record (case) in the database on the server and by transferring the answers to the same record on the database.
The new "open" telepathology system iPath (http://telepath.patho.unibas.ch) has been very well accepted by many groups around the world. The main application fields are: consultations between pathologists and medical institutions without a pathologist (e.g. for frozen section diagnoses or for surgical diagnoses in hospitals in South Asia or Africa), tumour boards, field studies and distance education (http://teleteach.patho.unibas.ch).
Having observed that with iPath we have succeeded in satisfying all our telepathology needs, we are inclined to put the emphasis on the nature of the tasks being performed, as opposed to the methods or technical means for performing a given task. The three organisation models proposed by Weinstein et al. (2001) can be reduced to only two models: the model of discussion groups and the model of expert groups (virtual institutes).
Introduction:
Teledermatopathology has the potential to revolutionize the practice of diagnosing skin diseases. This review provides an overview of the advantages, limitations, and future directions of teledermatopathology.
Methods:
MEDLINE was searched via PubMed and Google Scholar databases for relevant articles published from 2012 to the present. Additional articles were also identified by hand-searching.
Results:
A total of 2675 citations were identified in the initial search. Two thousand five hundred seventy-three were excluded based on duplicates and review of titles and abstracts. Eighty studies failed to meet the inclusion criteria, resulting in a total of 22 articles for analysis. Nine additional articles were hand-searched.
Conclusions:
Recent studies report that telepathology increases access to specialists, reduces interpretive errors and health care expenditures, improves the efficiency of workflow, and optimizes patient outcomes. It also facilitates international collaboration by widening global access to dermatopathology services and providing educational resources in underserved areas. However, the quality and regulations of digital slide imaging in teledermatopathology need to be improved.
Context:
- Telepathology is the practice of pathology at a distance, transmitting images using telecommunication methods for second opinion and/or diagnostic assistance, or for educational purposes. It may be the only means of consultation for some pathologists.
Objective:
- To retrospectively review and evaluate a subset of telepathology consultations from June 1996 to March 1997, and to determine the concordance between the telepathology diagnosis of the contributor and pathologists at the Armed Forces Institute of Pathology (AFIP), Washington, District of Columbia, as well as the concordance between the telepathology diagnosis and the glass slide diagnosis, when available.
Design:
- Photocopies of de-identified telepathology reports from the AFIP during a 15-month period between June 1996 and March 1997 were reviewed. Contributor versus telepathology diagnosis was graded as 1 (complete agreement), 2 (partial agreement), 3 (disagreement; usually a diagnosis of benign versus malignant), and deferred. Data were analyzed using descriptive statistical methods.
Results:
- Of the 262 cases, 194 (74%) were in complete agreement with the contributor's diagnosis, 34 of 262 (13%) were in minor disagreement, and 21 of 262 (8%) were in major disagreement. Diagnoses were deferred in 4% (13 of 262) of cases.
Conclusions:
- Using commercial off-the-shelf technology and despite telecommunication challenges during that time, the AFIP demonstrated that telepathology could be conducted reliably.
Introduction:
Telepathology evolved from video microscopy (i.e., "television microscopy") research in the early 1950s to video microscopy used in basic research in the biological sciences to a basic diagnostic tool in telemedicine clinical applications. Its genesis can be traced to pioneering feasibility studies regarding the importance of color and other image-based parameters for rendering diagnoses and a series of studies assessing concordance of virtual slide and light microscopy diagnoses. This article documents the empirical foundations of telepathology.
Methods:
A selective review of the research literature during the past decade (2005-2016) was conducted using robust research design and adequate sample size as criteria for inclusion.
Conclusions:
The evidence regarding feasibility/acceptance of telepathology and related information technology applications has been well documented for several decades. The majority of evidentiary studies focused on intermediate outcomes, as indicated by comparability between telepathology and conventional light microscopy. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include use of telepathology and whole slide imaging for teaching, research, and outreach to resource-limited countries. Challenges still exist, however, in terms of use of telepathology as an effective diagnostic modality in clinical practice.
The fourth edition of the World Health Organization (WHO) classification of tumours of the central nervous system, published in 2007, lists several new entities, including angiocentric glioma, papillary glioneuronal tumour, rosette-forming glioneuronal tumour of the fourth ventricle, papillary tumour of the pineal region, pituicytoma and spindle cell oncocytoma of the adenohypophysis. Histological variants were added if there was evidence of a different age distribution, location, genetic profile or clinical behaviour; these included pilomyxoid astrocytoma, anaplastic medulloblastoma and medulloblastoma with extensive nodularity. The WHO grading scheme and the sections on genetic profiles were updated and the rhabdoid tumour predisposition syndrome was added to the list of familial tumour syndromes typically involving the nervous system. As in the previous, 2000 edition of the WHO ‘Blue Book', the classification is accompanied by a concise commentary on clinico-pathological characteristics of each tumour type. The 2007 WHO classification is based on the consensus of an international Working Group of 25 pathologists and geneticists, as well as contributions from more than 70 international experts overall, and is presented as the standard for the definition of brain tumours to the clinical oncology and cancer research communities world-wide
Objective:
In this study, the efficiency of telemedical consulting with regard to fine needle aspirates from space-occupying lesions (SOLs) of the liver is investigated for the first time.
Study design:
The study includes fine needle aspirations from 62 patients, 33 with hepatocellular carcinoma (HCC) and 29 with non-hepatic tumors. Using the Internet-based iPath system, the initial pathologist submitted 1-8 images from smears and cell block sections. One consultant assessed the cytological and another one the histological images. Both made their diagnoses independent of each other. A final diagnosis was made by immunochemistry of cell block sections. The cytological images were analyzed retrospectively for the occurrence of the most typical HCC indicators. The number of these indicators was related to the initial diagnoses of the three pathologists, and possible reasons for diagnostic errors were analyzed based on this analysis.
Results:
The accuracy of the preliminary telemedical diagnoses regarding HCC was 82.0% for the cytological images and 87.7% for the histological images. Most of the false diagnoses occurred in tumors with unusual cytological and histological patterns.
Conclusions:
Telemedical consulting is a valuable tool to obtain a second opinion. However, for improvement of the diagnosis of HCC, supplementary immunochemical tests are necessary.
We established a hybrid telepathology network at the Children's Surgical Centre (CSC) in Cambodia, based on store-and-forward communication using iPATH and videoconferencing using Skype. We retrospectively analysed all data from the CSC stored on the iPATH server and reviewed the patient notes over an 8-month period. Of 115 patients for histopathology diagnosis during the study period, 38 cases were uploaded onto iPATH for further telemedicine discussion. The median number of days it took a specialist, other than the local one, to comment on the case on iPATH was 5 days (range 0-15). In three cases (8%) there was no reply from a specialist on iPATH. During the study period, seven clinical conferences were held, with an average of 6 cases (range 4-7) discussed at each conference. All 38 cases discussed had a final agreed diagnosis and firm management plans were made. Of the 24 cases where proactive management was advised, 17 patients followed through with the recommendations. Although the combination of video consultations and store-and-forward communication has not been used much before in the developing world, it has benefited patient care and outcomes at the CSC.
Telemicroscopy equipment is a key tool to perform Telepathology successfully. It allows the local separation of the microscope with the tissue samples from the investigating pathologist. The Telemicroscopy stations presented provide the user with a full access to the functions such as scanning stage, focus, illumination and magnification selection of a remote microscope. One system applies as communication link a broadband video conference net of the German Telekom with full realtime capabilities and color TV-image quality. As this network provides adequate interfaces for video and computer net signals, it is well suited to establish within a short time interval a very comfortable Telemicroscopy connection without the development of additional equipment. As the broadband network is expensive the application is economically restricted to special applications. The other system relies on the narrow band connections of the ISDN telephone network. This design is inexpensive with respect to data transmission and is available nearly worldwide everywhere. But on the other hand this strategy is limited concerning realtime capabilities. To reduce these limitations to an acceptable level intelligent coding and operation concepts of the stations have to be developed.
We investigated 109 randomly selected frozen section specimens from lung surgery patients in a retrospective blind mode using telepathology equipment. The telepathology system applied (HISTKOM) used one ISDN B-channel and telemicroscopy with a remotely operated robotic microscope. The performance of telepathological frozen section diagnosis was compared with that of conventional frozen section diagnosis. The false-positive rate achieved was identical for both methods. The sensitivity (P=0.03), but not the specificity, was significantly lower for the telepathological method. The time needed to establish a diagnosis with the remote microscope was too high; therefore, upgrading to multichannel technology is recommended. The quality of the images transmitted was judged to be sufficient by the pathologists involved in the study. In conclusion, with further technical improvements in telemicroscopy and additional experience in telepathology, remote diagnosis seems to be feasible.
Telepathology is the practice of pathology at a distance by using video imaging and telecommunications. Significant progress has been made in telepathology. To date, 12 classes of telepathology systems have been engineered. Rapid and ultrarapid virtual slide processors may further expand the range of telepathology applications. Next-generation digital imaging light microscopes, such as miniaturized microscope arrays (MMA), may make virtual slide processing a routine laboratory tool. Diagnostic accuracy of telepathology is comparable with that of conventional light microscopy for most diagnoses. Current telepathology applications include intraoperative frozen sections services, routine surgical pathology services, second opinions, and subspecialty consultations. Three telepathology practice models are discussed: the subspecialty practice (SSP) model; the case triage practice (CTP) model; and the virtual group practice (VGP) model. Human factors influence performance with telepathology. Experience with 500 telepathology cases from multiple organs significantly reduces the video viewing time per case (P < .01). Many technology innovations can be represented as S-curves. After long incubation periods, technology use and/or efficiency may accelerate. Telepathology appears to be following an S-curve for a technical innovation.
An early, point-to-point telepathology system at the University of Basel developed into an open-source, Internet-based platform for telemedicine in 2001. The Internet Pathology Suite (iPath) is a Web-based telepathology platform that permits the online presentation and discussion of cases within user groups. It also allows realtime telemicroscopy across firewalls. After four years, the telepathology network has over 700 active users. More than 6,300 cases with a total of about 39,000 images have been diagnosed. The diagnostic workload of all these cases is not exclusively handled by the Department of Pathology in Basel, but by a growing number of independent groups who also use the server simply as a case repository. What started as a small project for hospitals in Switzerland has become a global network.
- Glatz K
Current status and future trends in telepathology and digital pathology.
- T D Chordia
- A Vikey
- A B Choudary
Afghanistan platform. www.ipath.network.com Mazari Sharif Afghanistan
- R Rokai
- P Dalquen
- M Hubler
Benign cystic mesothelioma of the peritoneum in a 12-year old boy diagnosed via telepathology
- N Hinsch
- R Raoufi
- G Stauch
The empirical foundations of telepathology. Evidence of feasibility and intermediate effects.
- R L Bashshur
- Krupinski
- Ea
- R S Weinstein
Telepathology overview. From concept to implementation.
- R S Weinstein
- Descour
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- C Liang
Evaluation of android smartphones for Telepathology
- D Ekong
- F Liu
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Dermatopathology forum
- K A Aboud
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- M M Golam