Analytical Cellular Pathology - Volume 21, issue 3-4

Article Type: Other

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 95-96, 2000

Authors: Dierks, Christian

Article Type: Research Article

Abstract: In some legal surroundings telepathology is considered a breach of registrational barriers. The recommendation of the G 8 states in Europe for required legislation in telemedicine suggests to recognise that the localization of the remote health care professional defines the site not only of licensure but also of liability. This approach must be considered helpful, since it can solve many problems brought about by the doubtful results of private international law and conventions like the European Union (EU) and Lugano Convention. Under today's conditions in private international law it must be considered essential to agree upon a choice of law …and stipulate a court of jurisdiction when doing telepathology. However, the opposing aims of insuring the patients claims and avoiding jurisdictions that exceed the local expectations of the medical professional must be reconciled. Data protection and data security are other crucial topics that require attention. Generally speaking, the principles of minimum data exchange, anonymity, pseudonymity and cryptography must be established as a basis for all telepathology procedures. Only when personal data is needed, its use can be legitimated. Written consent of the patient is advised. To guarantee a cross‐border security level the regulations of the EU‐Data Protection Directive need to be transformed into national law. In practise, cross‐border dataflow shall only take place where the security level can be maintained even within the other country. Finally, reimbursement questions must be answered to establish a sound economical basis for telepathology. The spatial distance between the participants may yield the question, whether the service has been rendered to an extent necessary and sufficient for reimbursement. If reimbursement takes place on a cross‐border or cross‐regional level, severe disturbances of the health systems can occur. Regulation schemes or treaties need therefore to be developed to avoid such disturbances and encompass mutual standards of care as well as methods to balance reimbursement. Show more

Keywords: Telepathology, legal aspects, licensing, liability, data protection, data security, reimbursement

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 97-99, 2000

Authors: Kayser, K. | Beyer, M. | Blum, S. | Kayser, G.

Article Type: Research Article

Abstract: Telepathology which is the diagnostic work of a pathologist at a distance has been developed to routine application within the last ten years. It can be classified in relation to application, technical solutions, or performance conditions. Diagnostic pathology performance distinguishes primary diagnosis (for example, frozen section statement) from secondary diagnosis (for example, expert consultation) and quality assurance (diagnostic accuracy, continuous education and training). Applications comprise (a) frozen section service; (b) expert consultations; (c) remote control measurements; and (d) education and training. The technical solutions distinguish active (remote control, live imaging) systems from passive (conventional microscope handling, static imaging), and the …performance systems with interactive (on‐line, live imaging) use from those with passive (off‐line, static imaging) practice. Intra‐operative frozen section service is mainly performed with remote control systems; whereas expert consultations and education/training are commonly based upon Internet connections with static imaging in an off‐line mode. The image quality, transfer rates, and screen resolution of active and passive telepathology systems are sufficient for an additional or primary judgment of histological slides and cytological smears. From the technical point of view, remote control telepathology requires a fast transfer and at least near on‐line judgement of images, i.e., image acquisition, transfer and presentation can be considered one performance function. Thus, image size, line transfer rate and screen resolution define the practicability of the system. In expert consultation, the pixel resolution of images and natural color presentation are the main factors for diagnostic support, whereas the line transfer rate is of minor importance. These conditions define the technical compartments, especially size and resolution of camera and screen. The performance of commercially available systems has reached a high quality standard. Pathologists can be trained in a short time and use the systems in a routine manner. Several telepathology systems have been implemented in large Institutes of Pathology which serve for frozen section diagnosis in small hospitals located in the local area. In contrast, expert consultation is mainly performed with international connections. There is a remarkable increase of expert consultations by telepathology according to the experiences of the Armed Forces Institute of Pathology or the Department of Pathology, Thoraxklinik, Heidelberg. In expansion of these experiences, a “globalization” of telepathology can be expected. Telepathology can be used to shrink the period necessary for final diagnosis by request for diagnostic assistance to colleagues working in appropriate related time zones. Telepathology is, therefore, not a substitute of conventional diagnostic procedures but a real improvement in the world of pathology. Show more

Keywords: Telepathology, frozen section service, expert consultation, active telepathology, passive telepathology

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 101-106, 2000

Authors: Schwarzmann, P. | Binder, B. | Klose, R.

Article Type: Research Article

Abstract: Pathology undergoes presently changes due to new developments in diagnostic opportunities and cost saving efforts in health care. Out of the wide field of telepathology the paper selects three prototype applications: telepathology in teleeducation, expert advice for preselected details of a slide and finally telepathology for remote diagnosis. The most challenging field for remote diagnosis is the application in the frozen section scenario. The paper starts with the mental experiment to map conventional procedures to counterparts in telepathology. Technical opportunities and economical restrictions of telepathology equipment are discussed with respect to the components: electronic camera, display devices, haptic sensors …and displays, available telecommunication channels and telepathology software. As an example and for illustration of the state of the art for an advanced telemicroscopy system able to perform remote frozen section diagnosis, the HISTKOM equipment is presented in more details. The section concerning future developments regards the aspects of the acceptance by tentative users, legal aspects, costs and affordability of equipment, the market for equipment components and the adequate telecommunication services. Further is regarded the mutual influence of properties of existing systems and application experiences gained with them on the next generation of equipment and application software. Conclusions and references close the paper. Show more

Keywords: Telepathology, telepathology networks, artificial hand, teleeducation, virtual slide, telemedicine market

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 107-126, 2000

Authors: Della Mea, V. | Beltrami, C.A.

Article Type: Research Article

Abstract: The last five years experience has definitely demonstrated the possible applications of the Internet for telepathology. They may be listed as follows: (a) teleconsultation via multimedia e‐mail; (b) teleconsultation via web‐based tools; (c) distant education by means of World Wide Web; (d) virtual microscope management through Web and Java interfaces; (e) real‐time consultations through Internet‐based videoconferencing. Such applications have led to the recognition of some important limits of the Internet, when dealing with telemedicine: (i) no guarantees on the quality of service (QoS); (ii) inadequate security and privacy; (iii) for some countries, low bandwidth and thus low responsiveness for real‐time …applications. Currently, there are several innovations in the world of the Internet. Different initiatives have been aimed at an amelioration of the Internet protocols, in order to have quality of service, multimedia support, security and other advanced services, together with greater bandwidth. The forthcoming Internet improvements, although induced by electronic commerce, video on demand, and other commercial needs, are of real interest also for telemedicine, because they solve the limits currently slowing down the use of Internet. When such new services will be available, telepathology applications may switch from research to daily practice in a fast way. Show more

Keywords: Telepathology, Internet, multimedia, dynamic telepathology

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 127-134, 2000

Authors: Mairinger, Thomas

Article Type: Research Article

Abstract: The availability of pathology services differs greatly in our environment. Although pathology would be especially suitable for being practised at a distance by transporting digital image information, the spread of telepathology into everyday work still is relatively slow. The article describes the situation of diffusion of this innovative technology by reviewing the literature and discussing this in context to data based on questionnaires dealing with the acceptance of telepathology. The current situation of telepathology can be discussed by five items for innovation spead: (1) communication and influence; (2) economic costs and benefits; (3) knowledge barriers and learning; (4) feasibility …of techniques offered for the demands of the users; (5) clarification of the legal status and other factors concerning international collaboration. All these head lines do not represent realistic obstacles for the more widespread use of telepathology. The real drawbacks may therefore be found behind certain professional habits of pathologists. The most important causes may be that (a) telediagnosis is not as easy as it may seem at the first glance; (b) telepathology is seen as a potential highway to a world‐wide competition of pathology service providers. As soon as these mostly unjustified prejudices are corrected and telepathology is percepted as additional technique in pathology, it will become a diagnostic tool as common and as useful as the telephone. Show more

Keywords: Telepathology, social influence, cost/benefit ratio, Austria questionnaire

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 135-140, 2000

Authors: Gombas, Peter

Article Type: Research Article

Abstract: Application of computer and telecommunication technology calls serious challenges in routine diagnostic pathology. Complete data integration, fast access patients' data to usage of diagnosis thesaurus labeled with standardized codes and free text supplements, complex inquiry of the data contents, data exchange via teleconsultation and multilevel data protection are required functions of an integrated information system. Increasing requirement for teleconsultation transferring a large amount of multimedia data among different pathology information systems raises new questions in telepathology. Creation of complex telematic systems in pathology requires efficient methods of software engineering and implementation. Information technology of object‐oriented modeling, usage of client server …architecture and relational database management systems enables more compatible systems in field of telepathology. The aim of this paper is to present a practical example how to unify text based database, image archive and teleconsultation in a frame of an integrated telematic system and to discuss the main conceptual questions of information technology of telepathology. Show more

Keywords: Telepathology, telemedicine, information storage and retrieval, information science, ISDN, Internet

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 141-147, 2000

Authors: Haroske, G. | Giroud, Francoise | Kunze, K.D. | Meyer, W.

Article Type: Research Article

Abstract: An increasing need for flexible consultation between pathologists, including the application of fast evolving supplementary technologies, has been identified during the last years. Although pathology is already one of the most advanced application of telemedicine there is more to come from the fast evolution towards computerized microscope image analysis: A reproducible quantification of measurable descriptors of the lesions in cells and tissues (so‐called biological markers) is an indispensable adjunct to routine diagnostic application. Among such quantitative methods DNA image cytometry is increasingly applied by pathologists for assistance in diagnostics. As for other pathological issues, too, a reference center for …the clinical application of DNA image cytometry might be therefore of utmost value for pathologists using that method. Based on advanced telematic technologies, a Virtual Reference and Certification Center (VRCC) could be installed for certifying the cytometry hardware and software, the analytical procedures, and the basic interpretation of the results. It will be designed to be operated as a non‐attended service, based on quantification servers accessible via Internet round the clock. The VRCC will supply appropriate standardization and normalization materials and run a GroupWare platform for consensus making by experts. Show more

Keywords: Telepathology, DNA image cytometry, reference center, certification center

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 149-159, 2000

Authors: Hufnagl, P. | Bayer, G. | Oberbarnscheidt, P. | Wehrstedt, K. | Guski, H. | Hauptmann, S. | Dietel, M.

Article Type: Research Article

Abstract: In a retrospective study on a set of 125 cases we compared the following three telepathology solutions for primary frozen section diagnosis: ATM‐TP (connection via ATM), TPS 1.0 (connection via LAN) and TELEMIC (connection via Internet), which represent different concepts of telepathological procedures. A set of 125 routine frozen sections (breast) was selected from the Charité cases of the year 1999. Four experienced pathologists diagnosed retrospectively all of these cases using the ATM‐TP and TPS systems and 53 of them with the TELEMIC system. Using the ATM‐TP we recorded no false positive (0%), 4 false negative (3.2%) and …4 deferred (3.2%) cases. Using the TPS we recorded no false positive (0%), 4 false negative (3.2%) and 4 deferred (3.2%) cases. Using the TELEMIC we recorded in 53 cases no false positive (0%), no false negative (0%) and 16 deferred (30.2%) cases. The average time of 2.2 minutes per case using ATM‐TP is also short enough for routine frozen section diagnostic. This is also true for the TPS system with 7.2 minutes per case. Show more

Keywords: Telepathology, frozen section service, Internet, ATM video conferencing

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 161-167, 2000

Authors: Baak, J.P.A. | van Diest, P.J. | Meijer, G.A.

Article Type: Research Article

Abstract: Aim: To evaluate the feasibility of an inexpensive, generally applicable video‐conferencing system for frozen section telepathology (TP). Methods: A commercially widely available PC‐based dynamic video‐conferencing system (PictureTel LIVE, model PCS 100) has been evaluated, using two, four and six ISDN channels (128–384 kilobits per second (kbs)) bandwidths. 129 frozen sections have been analyzed which were classified by TP as benign, uncertain (the remark probably benign, or probably malignant was allowed), malignant, or not acceptable image quality. The TP results were compared with the original frozen section diagnosis and final paraffin diagnosis. Results: Only 384 kbs (3 ISDN‐2 lines) resulted in …acceptable speed and quality of microscope images, and synchronous image/speech transfer. In one of the frozen section cases (0.7%), TP image quality was classified as not acceptable, leaving 128 frozen sections for the analysis. Five of these cases were uncertain by TP, and also deferred by frozen section procedure (FS). One more benign and three malignant FS cases were classified as uncertain by TP. Three additional cases were uncertain by FS, but benign according to TP (in agreement with the final diagnosis). In one case, FS diagnosis was uncertain but TP was malignant (in agreement with the final diagnosis). Thus, test efficiency (i.e., cases with complete agreement) was 120/128 (93.8%, Kappa = 0.88) between FS and TP. Sensitivity was 93.5%, specificity 98.6%, positive and negative predictive values were 97.7% and 96.0%. Between TP and final diagnosis agreement was even higher. More importantly, there was not a single discrepancy as to benign‐malignant. Moreover, there was a clear learning effect: 5 of the 8 FS/TP discrepancies occurred in the first 42 cases (5/42=11.9%), the remaining 3 in the following 86 cases (3/86=3.5%). Discussion: The results are encouraging. However, TP evaluation is time‐consuming (5–15 min for one case instead of 2–4 min although speed went up with more experience) and is more tiring. The system has the following technical drawbacks: no possibility to point at objects or areas of interest in the life image at the other end, resolution (rarely) may become suboptimal (blocky), storage of images evaluated (which is essential for legal reasons) is not easy and no direct control of a remote motorized microscope. Yet, all users were positive about the system both for telepathology and personal contact by video‐conferencing. Conclusion: With a relatively simple videoconferencing system, accurate dynamic telepathology frozen section diagnosis can be obtained without false positive or negative results, although a limited number of uncertain cases will have to be accepted. Show more

Keywords: Telepathology, frozen section, diagnosis, dynamic, synchronous

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 169-175, 2000

Authors: Remmelinck, Myriam | Lopes, M. Beatriz S. | Nagy, Nathalie | Rorive, Sandrine | Rombaut, Katja | Decaestecker, Christine | Kiss, Robert | Salmon, Isabelle

Article Type: Research Article

Abstract: The present paper reports our experience with, and our opinion of static telepathology as applied to neuropathology by means of the PHAROS acquisition system and conventional telephone data transmission (modem). The classical procedure of expert consultation based on surface mailing of histological slides is routinely performed, especially in highly specialized fields of pathology. Telepathology is an easy means of sharing scientific expertise at international level and could thus improve diagnosis particularly in neuropathology, where certain tumor types are very rare and complex to diagnose. Dynamic telepathology allows the referring pathologist to capture by himself images supporting their diagnosis. Using static …telepathology the pathologist could be limited in diagnosis by problems in fields selection. We devoted a whole year to collecting all the technical parameters characterizing the use of digitized neuropathological data files in order to investigate the feasibility of telepathology and the extent to which its use could improve diagnoses. Our results on a series of 38 histological brain examinations illustrate how we successfully established an international connection between two departments of pathology in Belgium and the USA. The referring pathologists gave diagnoses in 35 cases and deferred only 3. Despite a time‐consuming procedure for the telepathology session of a few cases, this tool provides easy access to expert diagnosis and real‐time discussion, both of which are of considerable interest and offer significant improvements in neuropathology. Show more

Keywords: Static telepathology, neuropathology, data transmission, expert consultation

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 177-182, 2000

Authors: Szymas, Janusz

Article Type: Research Article

Abstract: Our experience in creating and using telepathology system and multimedia database for education is described. This program packet currently works in the Department of Pathology of University Medical School in Poznan. It is used for self‐education, tests, services and for the examinations in pathology, i.e., for dental students and for medical students in terms of self‐education and individual examination services. The system is implemented on microcomputers compatible with IBM PC and works in the network system Netware 5.1. Some modules are available through the Internet. The program packet described here accomplishes the TELEMIC system for telepathology, ASSISTANT, which is the …administrator for the databases, and EXAMINATOR, which is the executive program. The realization of multi‐user module allows students to work on several working areas, on random be chosen different sets of problems contemporary. The possibility to work in the exercise mode will image files and questions is an attractive way for self‐education. The standard format of the notation files enables to elaborate the results by commercial statistic packets in order to estimate the scale of answers and to find correlation between the obtained results. The method of multi‐criterion grading excludes unlimited mutual compensation of the criteria, differentiates the importance of particular courses and introduces the quality criteria. The packet is part of the integrated management information system of the department of pathology. Applications for other telepathological systems are presented. Show more

Keywords: Telepathology, teleeducation, automated score, teleteaching

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 183-191, 2000

Authors: Brauchli, K. | Christen, H. | Meyer, P. | Haroske, G. | Meyer, W. | Kunze, K.D. | Otto, R. | Oberholzer, M.

Article Type: Research Article

Abstract: Although telepathology systems have been developed for more than a decade, they are still not a widespread tool for routine diagnostic applications. Lacking interoperability, software that is not satisfying user needs as well as high costs have been identified as reasons. In this paper we would like to demonstrate that with a clear separation of the tasks required for a telepathology application, telepathology systems can be built in a modular way, where many modules can be implemented using standard software components. With such a modular design, systems can be easily adapted to changing user needs and new technological developments and …it is easier to integrate modular systems into existing environments. Show more

Keywords: Telepathology, expert system, modular design, robotic microscope

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 193-199, 2000

Authors: Stauch, G. | Schweppe, K.W. | Kayser, K.

Article Type: Research Article

Abstract: Telepathology (TP) as a service in pathology at a distance is now widely used. It is integrated in the daily workflow of numerous pathologists. Meanwhile, in Germany 15 departments of pathology are using the telepathology technique for frozen section service; however, a common recognised quality standard in diagnostic accuracy is still missing. In a first step, the working group Aurich uses a TP system for frozen section service in order to analyse the frequency and sources of errors in TP frozen section diagnoses for evaluating the quality of frozen section slides, the important components of image quality and their influences …an diagnostic accuracy. The authors point to the necessity of an optimal training program for all participants in this service in order to reduce the risk of diagnostic errors. In addition, there is need for optimal cooperation of all partners involved in TP service. Show more

Keywords: Telepathology, frozen section service, diagnostic error

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 201-206, 2000

Authors: Kayser, K. | Kayser, G. | Becker, H.D. | Herth, F.

Article Type: Research Article

Abstract: Aim: To analyze the diagnostic accuracy of telediagnostic procedures for transbronchial fine needle aspirations. Material and methods: A double blind study was performed on cytological slides of 54 randomly selected cases with transbronchial fine needle aspirations. The slides were digitized using a Leica digital camera DC100 mounted on a microscope Leica Laborlux S, and analyzed by an experienced pathologist without knowing the definite diagnosis or any additional clinical data. The diagnoses stated by analyzing the digital images were compared to the final conventional diagnoses. In addition, the duration of the digital diagnosis, used magnifications, and difficulties for correct sampling were …documented. Results: The “digital” diagnoses of the 54 cases were all in general agreement with the definite diagnoses. No wrong positive or wrong negative case in respect to malignant/non‐malignant (31/23) or to small cell/non‐small cell (9/22) occurred. The performance of a digital diagnosis lasted for 115 s at average (15–260 s), and is significantly longer compared to that of conventional fine needle aspiration judgement (20 s). The screening magnification was commonly set to ×2.5, that for definite diagnostic analysis ×40. Benign diseases (2 tuberculosis and 3 sarcoidosis cases) were correctly classified. Conclusions: Telepathology systems can probably be used for fine needle aspiration analysis without major diagnostic errors. Their use can improve the endoscopic sampling and avoid second anesthesia when missing the lesion of request during the first examination. Show more

Keywords: Fine needle aspiration, lung, telepathology, feasibility study

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 207-212, 2000

Authors: Wellnitz, Uwe | Binder, Bernd | Fritz, Peter | Friedel, Godehard | Schwarzmann, Peter

Article Type: Research Article

Abstract: 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. Show more

Keywords: Telepathology, frozen section diagnosis, diagnostic accuracy, metaanalysis

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 213-222, 2000

Authors: Seiwerth, S. | Danilovic, Z.

Article Type: Research Article

Abstract: Telepathology as a demanding branch of telemedicine poses a real challenge to experts. The introduction of telepathology in underprivileged countries with poor infrastructure and low health‐care budget is a difficult task. On the other hand these countries would mostly benefit by introducing telemedicine/telepathology. In our experience it is possible to build an efficient telepathology/teleradiology network using analogue telephone links and still image transmission, and a store and forward mode of operation. This experience is based on the application of telepathology in Croatia for seven years leading to a national teleradiology network. In this paper the ideas, development and software solutions …in the process of establishing a national telepathology and teleradiology network are highlighted. Show more

Keywords: Telepathology, Croatia, teleradiology, still image transmission

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 223-228, 2000

Authors: Tennstedt, Cornelia | Sunkel‐Wehrstedt, Kathrin | Vogel, Martin | Hufnagl, Peter

Article Type: Research Article

Abstract: Goal: In a study of 10 autopsy cases with congenital cardiac malformations we investigated whether obtaining a second opinion by means of telepathology could satisfy quality standards for the diagnosis of cardiac malformations and what the advantages and disadvantages of such a procedure might be. Material: The investigatory samples were 10 formalin‐fixed hearts with complex malformations from 9 fetuses and one newborn on which autopsies had been performed at the Pathological Institute of the Charité Hospital. The requests for a second opinion, which included text and image data, were sent in the form of Microsoft PowerPoint presentations to 5 experts …in 4 countries. Per case the number of images that were sent was between 3 and 7. The size of the files was between 439 and 942 kb. The time required for preparation of the cases for sending them to the specialists was between 1 and 2 hours: this encompassed the time for putting the notation on the images, compressing them, creating a file that included both the images and the clinical data and then sending the case file. Results: All 10 cardiac malformations were correctly identified. In 8 of the 10 cases at least one expert had questions. After these questions had been answered and further images had been sent final correct diagnoses were made in all cases. All experts said that the quality of the images was very good. Use of a standardized findings questionnaire, which also included the marking of anatomic structures and of pathological findings in the images, proved useful. Standardized findings forms facilitate orientation during interpretation of the cases and should be used generally to avoid misunderstandings in telepathological communication. Conclusions: In general it is possible to obtain an effective and reliable diagnosis of congenital heart malformations by means of telepathology. It is far quicker to get a second opinion by this means than by conventional means. Show more

Keywords: Congenital cardiac malformation, post‐mortem examination, telepathology, second opinion

Citation: Analytical Cellular Pathology, vol. 21, no. 3-4, pp. 229-235, 2000