Telemedicine for improving access to health care in resource-constrained areas : from individual diagnosis to strengthening health systems

In many developing countries there is an acute shortage of trained medical specialists. This does not only hamper individual patients’ access to medical diagnostics but furthermore limits the development of health systems because a major role of the specialists is the provision of continuous medical education of health care personnel. The rapid development of information and communication technologies has enabled radically new forms of virtual collaboration at a distance. So-called telemedicine enables us today to transmit knowledge to the patient rather than to only transport patients to the centres where the knowledge is available; this has promising implications in particular for remote and under-served areas. Initiated by a request from a Swiss surgeon from Solomon Islands, a project for supporting the hospital in Honiara, capital of Solomon Islands, with pathology diagnoses was started between Honiara and the Department of Pathology in Basel in 2001. After a successful start this pilot project found broad interest, and the Internet platform that had been developed was soon utilised by projects from other countries and medical disciplines. Thus, questions arose about the diagnostic accuracy of such remote diagnoses as well as about their acceptance and impact on the local health care system. The work presented here was initiated on this background. It analyses the applicability of telemedicine in the context of resource-constrained areas and in particular the possibilities to extend its impact from improving individual diagnosis towards strengthening health care systems. A central part of this project was the development of iPath, an Internet- and email-based telemedicine platform, which facilitates medical consultations, knowledge exchange and continuous education on a global scale. A particular emphasis was put on the applicability and accessibility for users from developing countries with limited infrastructure and network connectivity. The complete software was released under an open-source licence in order to allow unrestricted reuse for other institutions. The diagnostic accuracy of this form of telemedicine was studied in two projects from the field of pathology. A retrospective review of over 200 glass slides from each project revealed complete diagnostic concordance between the telemedical diagnosis and review diagnosis in 69% and 85% respectively. Clinically relevant discrepancies were found in 8% and 3.3% of all examinations. Selection of images by the non-expert and communication were found to have the greatest impact on diagnostic accuracy. Both factors can be addressed by training and organisation of workflow. In comparison to submitting material for pathological examination by courier, the turn-around time could be reduced from weeks to days or hours. Besides the more rapid availability of diagnosis, telemedicine enabled a direct dialogue between the surgeon and the pathologist and thus facilitated an implicit permanent medical education. The educational aspects of telemedicine were studied within the scope of a tele-dermatology project in South Africa. Distance collaboration with a dermatologist empowered a general practitioner based in a rural area to diagnose and treat a majority of patients with dermatological problems. Besides the direct benefit of saving the patients the cost of transportation to visit the dermatologist, the general practitioner could strengthen his own diagnostic skills under direct guidance and quality control of a specialist. As a consequence he will be able to treat more patients locally, close to their homes and families. The whole project was implemented within the local health system in order to facilitate a future inclusion of other primary care facilities. Regional telemedicine networks play a major role to ensure relevance and acceptability of consultative and educational telemedicine. Within the scope of the Ukrainian Swiss Perinatal Health Program a telemedicine component was included, and it was found that the use of regional language as well as inclusion of the regional specialists are important for the acceptance of telemedicine and should not be neglected in a era of globalisation. The presented results demonstrate that save and reliable telemedicine can be implemented with limited resources. Telemedicine is suitable in particular to strengthen existing international collaborations and to support professionally isolated medical specialists. Regional collaboration and inclusion of regional specialists are desirable if telemedicine shall help to strengthen health care systems. The application of telemedicine should not only focus on providing care to individual patients, but should explicitly incorporate skills development and capacity building of primary care staff. Organisation of work flow and communication have been found to be the most challenging task for the implementation of telemedicine networks. Resources must be invested not only in technology but more importantly in training and organisation. Utilisation of existing technological infrastructure is advisable wherever possible and greatly reduces the complexity of providing support and maintenance. The presented telemedicine platform provides an efficient tool for the organisation of interdisciplinary, regional and international telemedicine networks. We hope that the unrestricted availability of the software developed during this project will enable other institutions to utilise it for their own purpose and that they will thus be able to allocate resources on the organisation of workflow rather than technology

Developing/testing a new approach for assessing rapid visual identification of hematological cells using principles of visual cognition: a health science education study

The purpose of this study was the development and testing of a novel method for assessment of white blood cell (WBC) identification skills used in the field of Clinical Laboratory Sciences (CLS). A dual format exam was administered to both novices (students) and experts (laboratory professionals). Format 1 was similar to current assessment formats, simply presenting a series of single WBC images for identification. Format 2 applied principles of visual cognition, grouping WBCs for identification by patient and presenting multiple example images from the patient before requesting identification of individual cells. This novel exam format was intended to: (a) provide a contextualized visual background for single cell identifications, (b) mirror the process of WBC identification used in clinical practice, and (c) promote improved performance on difficult/atypical WBC identifications. The second phase of this study implemented qualitative methods to categorize the general cognitive processing styles used by novices/experts as either analytical or similarity-based. Cognitive processing styles were compared across the 2 levels of expertise as well as across exam formats. Statistical analyses did suggest that expert performance levels were significantly improved by the novel exam presentation format. Novice performance, however, was not significantly altered by exam format. Evaluation of response times indicated that expert response times were significantly shorter than novice response times in format 2, but not in format 1. In addition, analysis of qualitative data suggested that experts differed significantly from novices in their cognitive verbalizations for format 2, with experts making more statements at a higher cognitive level than did the novices. Format 1 verbalization differences were not found to be significant. Overall results indicated that the novel exam format invoked experts to implement similarity-based processing, allowing some identifications to be made at the level of the patient case, rather than simply at the feature identification level. Implications of this study include possible alterations to current certification/proficiency exam formats for questions requiring the visual identification of white blood cells. This study also suggests that using patient image sets as instructional stimuli may encourage the development of advanced cognitive processing skills in students

Digital image processing for prognostic and diagnostic clinical pathology

When digital imaging and image processing methods are applied to clinical diagnostic and prognostic needs, the methods can be seen to increase human understanding and provide objective measurements. Most current clinical applications are limited to providing subjective information to healthcare professionals rather than providing objective measures. This Thesis provides detail of methods and systems that have been developed both for objective and subjective microscopy applications. A system framework is presented that provides a base for the development of microscopy imaging systems. This practical framework is based on currently available hardware and developed with standard software development tools. Image processing methods are applied to counter optical limitations of the bright field microscope, automating the system and allowing for unsupervised image capture and analysis. Current literature provides evidence that 3D visualisation has provided increased insight and application in many clinical areas. There have been recent advancements in the use of 3D visualisation for the study of soft tissue structures, but its clinical application within histology remains limited. Methods and applications have been researched and further developed which allow for the 3D reconstruction and visualisation of soft tissue structures using microtomed serial histological sections specimens. A system has been developed suitable for this need is presented giving considerations to image capture, data registration and 3D visualisation, requirements. The developed system has been used to explore and increase 3D insight on clinical samples. The area of automated objective image quantification of microscope slides presents the allure of providing objective methods replacing existing objective and subjective methods, increasing accuracy and rsducinq manual burden. One such existing objective test is DNA Image Ploidy which seeks to characterise cancer by the measurement of DNA content within individual cell nuclei, an accepted but manually burdensome method. The main novelty of the work completed lies in the development of an automated system for DNA Image Ploidy measurement, combining methods for automatic specimen focus, segmentation, parametric extraction and the implementation of an automated cell type classification system. A consideration for any clinical image processing system is the correct sampling of the tissue under study. VVhile the image capture requirements for both objective systems and subjective systems are similar there is also an important link between the 3D structures of the tissue. 3D understanding can aid in decisions regarding the sampling criteria of objective tests for as although many tests are completed in the 2D realm the clinical samples are 3D objects. Cancers such as Prostate and Breast cancer are known to be multi-focal, with areas of seeming physically, independent areas of disease within a single site. It is not possible to understand the true 3D nature of the samples using 2D micro-tomed sections in isolation from each other. The 3D systems described in this report provide a platform of the exploration of the true multi focal nature of disease soft tissue structures allowing for the sampling criteria of objective tests such as DNA Image Ploidy to be correctly set. For the Automated DNA Image Ploidy and the 3D reconstruction and visualisation systems, clinical review has been completed to test the increased insights provided. Datasets which have been reconstructed from microtomed serial sections and visualised with the developed 3D system area presented. For the automated DNA Image Ploidy system, the developed system is compared with the existing manual method to qualify the quality of data capture, operational speed and correctness of nuclei classification. Conclusions are presented for the work that has been completed and discussion given as to future areas of research that could be undertaken, extending the areas of study, increasing both clinical insight and practical application

Methods for Analysing Endothelial Cell Shape and Behaviour in Relation to the Focal Nature of Atherosclerosis

The aim of this thesis is to develop automated methods for the analysis of the spatial patterns, and the functional behaviour of endothelial cells, viewed under microscopy, with applications to the understanding of atherosclerosis. Initially, a radial search approach to segmentation was attempted in order to trace the cell and nuclei boundaries using a maximum likelihood algorithm; it was found inadequate to detect the weak cell boundaries present in the available data. A parametric cell shape model was then introduced to fit an equivalent ellipse to the cell boundary by matching phase-invariant orientation fields of the image and a candidate cell shape. This approach succeeded on good quality images, but failed on images with weak cell boundaries. Finally, a support vector machines based method, relying on a rich set of visual features, and a small but high quality training dataset, was found to work well on large numbers of cells even in the presence of strong intensity variations and imaging noise. Using the segmentation results, several standard shear-stress dependent parameters of cell morphology were studied, and evidence for similar behaviour in some cell shape parameters was obtained in in-vivo cells and their nuclei. Nuclear and cell orientations around immature and mature aortas were broadly similar, suggesting that the pattern of flow direction near the wall stayed approximately constant with age. The relation was less strong for the cell and nuclear length-to-width ratios. Two novel shape analysis approaches were attempted to find other properties of cell shape which could be used to annotate or characterise patterns, since a wide variability in cell and nuclear shapes was observed which did not appear to fit the standard parameterisations. Although no firm conclusions can yet be drawn, the work lays the foundation for future studies of cell morphology. To draw inferences about patterns in the functional response of cells to flow, which may play a role in the progression of disease, single-cell analysis was performed using calcium sensitive florescence probes. Calcium transient rates were found to change with flow, but more importantly, local patterns of synchronisation in multi-cellular groups were discernable and appear to change with flow. The patterns suggest a new functional mechanism in flow-mediation of cell-cell calcium signalling

DROPLET MAGNETOFLUIDIC TECHNOLOGY FOR THE DELIVERY OF MOLECULAR DIAGNOSTICS AT THE POINT OF CARE

Molecular diagnostic techniques play an increasingly important role in modern medicine. The introduction of highly sensitive and rapid analytical techniques for detection of specific nucleic acid sequences continue to establish new standards of care in areas of emergency care such as pathogen identification. Ongoing research in nucleic acid biomarkers for various types of cancer and neurodegenerative conditions highlight the increasing role that molecular diagnostics will play in the future of medicine. Harnessing these technologies for diagnostic applications at the point of care has the potential to enhance the efficiency of diagnosis and treatment via reduction in both the cost and turnaround time of diagnostic testing at all levels of healthcare delivery. However, the complexity of conventional workflow for sample and reagent handling presents a conceptual hurdle in developing a robust and cost-effective system for point of care diagnostics. A promising solution may be found in droplet magnetofluidic technology. Past research in this field has demonstrated the potential of unique fluidic control mechanism facilitated solely by magnetic particles. Association, dissociation and transport of sessile droplets on hydrophobic substrates suggest a mode of fluid handling that is quite foreign to conventional approaches involving pneumatics or centrifugation. Indeed, investigators were not ignorant to the ramifications of this technology in medicine. With the advent of ‘smart’ particles with a magnetizable core whose surfaces could be used to capture and transport specific biomolecules, droplet magnetofluidics is well-poised to bring the pieces together and usher in a new workflow paradigm for biomolecular assays – one which is more portable and simpler to operate. This thesis investigates the use of droplet magnetofluidics as an enabling technology for point of care diagnostics. Following an introduction to the fundamentals of droplet magnetofluidic kinematics, we conceptualize a novel assay paradigm referred to as ‘single-stream assay workflow’ describing a linear workflow driven by analyte capture and transport on a movable magnetic particle cluster. Chapters 2 and 3 illustrate examples of single-stream bioassays that are enabled by the droplet magnetofluidic process for genetic and epigenetic biomarker analysis. Afterwards, we expand our investigation to various components of a complete platform, namely conceptualization and design of a cartridge and an instrument for process automation. Chapter 4 illustrates an example of process integration enabled by a combination of droplet magnetofluidic cartridge and a programmable magnetic actuator. Chapter 5 provides a discussion of design considerations for various aspects of the platform including the cartridge, instrument and the assay, with an emphasis on factors that must be considered in order to bridge the gap between a proof-of-concept and a field-ready platform. Lastly, we integrate our findings in order to develop a user-friendly diagnostic platform for the evaluation of droplet magnetofluidic workflow in a clinical setting. In Chapter 6, we illustrate a smartphone-based mobile nucleic acid testing station for the evaluation of chlamydia infection in emergency room setting. We will conclude our report with a discussion of future directions for droplet magnetofluidic technology in point of care testing. It is our hope that these findings will inspire the readers to appreciate the wide range of academic and commercial opportunities that droplet magnetofluidics presents to the biomedical field

Aerospace medicine and biology: A continuing bibliography with indexes (supplement 377)

This bibliography lists 223 reports, articles, and other documents recently introduced into the NASA Scientific and Technical Information System. Subject coverage includes: aerospace medicine and physiology, life support systems and man/system technology, protective clothing, exobiology and extraterrestrial life, planetary biology, and flight crew behavior and performance

Compresión de vídeo en telepatología usando compressing sensing

En las poblaciones apartadas el acceso servicios de salud y tecnológicos es bastante limitado, los recursos económicos son escasos, ya que actividades que son sencillas en las poblaciones principales están ausentes o tiene baja oportunidad en la poblaciones remotas, como por ejemplo el análisis de muestras citologícas de cuello uterino para las mujeres. Este trabajo explora técnicas y herramientas para crear una plataforma viable de telepatología, el problema se ha abordado en tres etapas. Primero se busco una solución para tener una navegación libre del patólogo sobre la muestra, para esto se construyo un sistema que es capaz de controlar con precisión los movimientos del microscopio. Segundo se desarrollo un sistema que fuera capaz de controlar dicho dispositivo desde un sitio remoto usando Internet. Por ultimo se explora una técnica de super-resolución de imágenes de una patología específica.Maestrí

Medical Robotics

The first generation of surgical robots are already being installed in a number of operating rooms around the world. Robotics is being introduced to medicine because it allows for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, robots have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. The use of robotics in surgery will expand over the next decades without any doubt. Minimally Invasive Surgery (MIS) is a revolutionary approach in surgery. In MIS, the operation is performed with instruments and viewing equipment inserted into the body through small incisions created by the surgeon, in contrast to open surgery with large incisions. This minimizes surgical trauma and damage to healthy tissue, resulting in shorter patient recovery time. The aim of this book is to provide an overview of the state-of-art, to present new ideas, original results and practical experiences in this expanding area. Nevertheless, many chapters in the book concern advanced research on this growing area. The book provides critical analysis of clinical trials, assessment of the benefits and risks of the application of these technologies. This book is certainly a small sample of the research activity on Medical Robotics going on around the globe as you read it, but it surely covers a good deal of what has been done in the field recently, and as such it works as a valuable source for researchers interested in the involved subjects, whether they are currently “medical roboticists” or not

Space Station Freedom Utilization Conference

The topics addressed in Space Station Freedom Utilization Conference are: (1) space station freedom overview and research capabilities; (2) space station freedom research plans and opportunities; (3) life sciences research on space station freedom; (4) technology research on space station freedom; (5) microgravity research and biotechnology on space station freedom; and (6) closing plenary