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PubMed2004

[Telemedicine in the maritime environment--hightech with a fine tradition].

Access to health care always has been one of the most critical issues for offshore crews. Therefore, telemedicine has a long and outstanding tradition in the maritime environment. Since 1931 Cuxhaven medical center (Medico Cuxhaven) operates as a hospital-based radio medical advice center (RMA) for ships worldwide providing one of the first routine telemedical services worldwide. For a long time this task was performed on a honorary basis by the hospital's physicians. In 1994 Germany accepted the IMO/ILO (International Maritime Organisation and International Labour Organisation) solution 164. Therefore, in 1998 a formal contract of the German Ministry of Transport officially installed Medico Cuxhaven as the TMAS Center for Germany. According to IMO/ILO solution 164, the RMA provides an expert level of care 24 h/day, 365 days/year. Cuxhaven hospital is a busy general hospital with departments of anesthesia and intensive care, internal medicine, surgery, gynecology and obstetrics, urology, pediatrics, ENT, radiology, and pain medicine. All physicians directly responding to TMAS calls have practical experience in maritime routine and emergency medicine. All incoming emergency calls are primarily handled by board-certified anesthesiologists, experienced in martime emergency medicine (e. g., staffing coastal SAR helicopters, working on rescue boats, carrying out repatriation services for sailors worldwide). If needed, other medical specialists are included. Today, Medico Cuxhaven takes an average workload of one to two emergency calls (response time < 20 s), two to three follow-up calls and approximately one informative call per day. Since 2000 transmission of digital photos has been used for routine RMA. Recently, a system for online and trenddata telemetry of twelve-lead ECG, NIBP (noninvasive blood pressure measurement), CO(2), SaO(2), pulse and respiration rates including the transmission of video images was developed. This system allows worldwide communications as it is capable of all possible means of telecommunication such as GSM, Inmarsat-ISDN or Iridium-Satellite-Transmission. So far, this system has been installed on board several German SAR rescue boats.However, radio telephone and the simple transmission of digital photography remain the basis of maritime radio medical advice service.

Adult↗
PubMed2003

The impact of gross tumor volume (GTV) and clinical target volume (CTV) definition on the total accuracy in radiotherapy theoretical aspects and practical experiences.

AIM: To evaluate the impact of interobserver variability in the contouring of gross tumor volumes (GTVs) and clinical target volumes (CTVs) on the global geometric accuracy in radiation therapy. MATERIAL AND METHODS: In a review of the currently available literature, the magnitude of interobserver variability is analyzed, causes and consequences are discussed. Uncertainties due to inconsistencies in contouring are related to other sources of geometric errors, particularly patient positioning and organ motion. RESULTS: Interobserver variability is a major -- for some tumor locations probably the largest -- factor contributing to geometric inaccuracy. Causes are multifactorial and include image- and observer-related factors, such as the subjective interpretation of image information. CONCLUSION: Consequences to reduce interobserver variability are proposed, among others the selection of adequate imaging modalities, intensified radiologic training, and the use of telecommunication tools.

Clinical Competence↗
PubMed2004

[Interdisciplinary surgery and telemedicine].

Surgical therapy is becoming increasingly complex. Besides new surgical techniques, sophisticated diagnostic methods and innovative interventional procedures must be integrated into the therapeutic concept to increase the efficacy of surgery. Accurate application of these techniques requires close cooperation between surgeons, other medical specialists, and technicians. Consequently, there is a significant need for structures promoting efficient communication, organization, and interaction in surgical departments. New techniques developed from telecommunication and information technology enable the transferal of complex medical data at any time to any place and are therefore the basis for telemedical applications. Telemedicine and other new techniques such as virtual operation planning, simulation, and intraoperative navigation promise to increase the efficacy of surgical therapy in the future. This paper provides an overview of the applications of telesurgery and currently available techniques.

Computer Communication Networks↗
PubMed1999

[The situation of oncological surgery in Germany in 1998: results of a current survey].

The situation of oncological surgery in Germany was evaluated by sending a questionnaire in January 1998 to 1979 registered surgical clinics. A total of 938 responded and stated that they are involved in that field. In 72% of the departments oncological surgery adds up to 10-30% of their overall work. The proportion of oncological surgery correlated to hospital size and is highest in university clinics. Colorectal surgery is 93% and is the leading topographical field in oncological surgery. 73% of the hospitals regularly perform gastric tumor surgery. The proportion of hospitals with breast surgery is surprisingly high (45%). Many hospitals (54.6%) report neoadjuvant treatment regimens. Together with adjuvant therapy this rate amounts to 85.2%. The diagnostic spectrum of the hospitals involved in the inquiry is satisfactory. However, the modern possibilities of network and telecommunication are not sufficiently used. A second opinion is required predominantly in their own department or clinic, but not between centers. The surgeon's position concerning the speciality "surgical oncology" is ambivalent: only 35.3% of the department chiefs support this speciality--and over 90% of the departments reject the structural independence of "surgical oncology" from "visceral surgery".

Germany↗
PubMed2002

[Stereotactic telepresence in otorhinolaryngologic surgery].

BACKGROUND: Intraoperative three-dimensional (3D) navigation systems determine spatial positions and visualize them in radiological data sets. Usually, data from 3-D computed tomography (CT) are used. We have successfully implemented "augmented reality" in routine clinical practice by superimposing positional data and guiding and ancillary structures on the live endoscopic video of the operating site. Thus, optimal access paths and anatomical structures such as the a. carotis interna or the n. opticus can be displayed. METHODS AND RESULTS: With modern telecommunication, any two locations can be connected for intraoperative consultations with a remote expert, and 3D navigation is an ideal complement. We have successfully tested telephone, ISDN, Ethernet, and ATM technology intraoperatively and find that the ARTMA system provides well-developed technology. CONCLUSIONS: Stereotactic telepresence can provide essential aid in difficult surgical procedures, and the ARTMA Knowledge-Guided Surgery system will contribute further to the optimization of computer-assisted surgery.

Endoscopes↗
PubMed2006

[The tele-visit as a telemedical technique in daily clinical practice. First results for elbow joint arthrolysis].

Technologies in telecommunication and information are being increasingly applied in the public health system of the western world. Also responsible for this development is the cost factor in the field of financing and maintenance of such a system of superior medical supply, as well as the concurrent patient' demand for optimized medical "24 h care and treatment". Pioneers in the use of telematic projects have, up until now, been large states such as the USA, Canada, Norway or Australia. Such projects have been used to provide, guarantee and maintain medical care in geographically remote regions with few medical facilities. After breaking the obstacle of geographic distance, telemedical solutions in general, and especially the tele-visit, represent a new form of treatment for patient care after discharge from hospital. In the year 2002, a prospective randomized two-armed study was initiated including patients after surgical intervention by arthroplasty in posttraumatic contracture of the elbow. The system of the tele-visit was used for 6 weeks after discharge and the patients were controlled as outpatients after 6 months, including a physical examination. The functional outcome, duration of stay in hospital and the costs for treatment arising were determined. A standardized questionnaire was developed and the degree of satisfaction of the patients surveyed. A shorter stay in hospital was found together with lowered costs in medical treatment, while no differences in functional outcome could be found in comparison to the control group, although there was an additionally high grade of satisfaction with the new system.

Adolescent↗
PubMed2002

[Teleconsultation 2001--report of the Teleconsultation Study Circle of the Austrian Roentgen Society (ORG)].

In 1997, the working group "Teleconsultation" of the Austrian Roentgen Society (ORG) has performed a first survey about the status of teleradiological applications in Austria. Now, in 2001, a second survey was performed in order to adapt the ORG's approach in this field to the most actual needs. Most of the 38 teleradiological projects in Austria already working or shortly before inauguration are aiming at an improvement of the medical service in favour of our patients (expert consultation, image transfer to doctors requesting radiological examinations, clinical case discussion). However, a small but not unimportant fraction of teleradiology projects in Austria (11%) is performed for replacement of radiologists on duty, therefore for reasons mainly directed to minimising costs for the hospital administration. Other purposes of teleradiology projects, like quality assurance and medical education have even lost their small importance the 1997 survey already has shown. This paper discusses the professional implications from the results of the 2001 survey and the legal framework for the application of telecommunication in diagnostic radiology. The most important goal of all professional activities in radiology is the well-being of our patients, based on the immediacy of the medical profession in accordance with the "physician law".

Austria↗
PubMed1999

[Dental CT in the planning of surgical procedures. Its significance in the oro-maxillofacial region from the viewpoint of the dentist].

Dental computer assisted tomography (Dental CT) represents a valuable addition to the diagnostic spectrum for planning oral and maxillofacial surgery. High resolution CT and specially designed computer software allow representation of the jaws in different planes that are easy to match. They further allow the display of very small structures relevant to oral surgical interventions and reveal their spatial relationship in three dimensions. Thus communication between dentists and radiologists may be intensified and supported by usage of modern telecommunication systems. Dental CT is indicated, when clinical and conventional radiological techniques will not allow exact interpretation of the situation. It is modern oral implantology that primarily benefits from computer software enabling the assessment of surgical sites in the presurgical phase. Such planning was not yet possible using two dimensional radiographic techniques. The dental-implantological part expects from radiography sharply defined contours of the external bony contours and the mandibular canal, exactly defined relation between slices and planes, no distortion in the orthoradial planes, tools for reliable measurements of distances, angles and volumes, possibility to transmit pictures electronically or on hardcopy without loss of quality.

Humans↗
PubMed2002

[Geometry of laparoscopy, telesurgery, training and telementoring].

Laparoscopic surgery in general is handicapped by the reduction of the range of motion from 6 to 4 degrees of freedom. This has a major impact on technically difficult procedures such as laparoscopic radical prostatectomy. Solutions for this problem include understanding the geometry of laparoscopy with sophisticated training programs, but also newly developed surgical robots, computer simulators, and telementoring. This article evaluates the value of these alternatives based on own experience and an analysis of the current literature. Our experience with robot-assisted surgery includes 244 laparoscopic radical prostatectomies using a voice-controlled camera arm (AESOP) and 6 telesurgical interventions with the da Vinci system. Additionally, experimental studies were performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and computer simulation. Three-dimensional systems have not yet proved to be effective due to handling problems such as shutter glasses, video helmets, or reduced brightness. At present, there are only two robotic surgical systems (ZEUS, da Vinci) in clinical use for telesurgery, of which only the da Vinci provides stereovision and all 6 degrees of freedom (DOF). In the meantime, more than 100 laparoscopic radical prostatectomies have been performed with this system. However, there was no evidence of any advantages over the conventional laparoscopic approach. The ZEUS in combination with the telecommunication system SOKRATES is the only device that enables telemanipulation and telementoring over long distances (i.e., transatlantic). Robotic surgery represents a turning point in surgical research. However, broad use of robotic systems is limited mainly because of high investment and running costs. Whereas audiovisual telementoring will play a clear role in future training concepts, the need for telemanipulation or telesurgery has not yet been clarified.

Computer Simulation↗
PubMed2001

Telementoring and teleproctoring.

Telemedicine has previously been defined as "live two-way interactive video communication between a physician and a patient and/or another physician, where all participants are able to see and hear one another much like a face to face encounter." This concept has gained recent notoriety because of the great advances in telecommunications and the potential future increased cost-effectiveness associated with its utilization. We have developed a telementoring deployment protocol that can be effectively used to introduce a student to telementoring processes. The strict protocol uses military commands to facilitate smooth information transfer. The use of a concept called tactical information deployment provides the surgeon with rapid access to reference information in the operating suite. Multimedia interactive CD-ROMs, with digitized movie clips, illustrations, sound bits, and the latest academic review of the literature arm the surgeon with a database that establishes an unprecedented clinical adaptive capability (CAC). The availability of this information is invaluable to surgeons in their initial advanced laparoscopic procedural efforts. Telementoring simulator opportunities are included to acclimate the participant to the process. If the process seems comprehensive, it is meant to be. This is a high-risk situation, and a patient's welfare is on the line. If this concept is to reach its maximal healthcare delivery potential, responsible and academically credible training programs should be established with directional guidelines.

Computer-Assisted Instruction↗
PubMed2001

Telemedicine, the Internet, and world wide web: overview, current status, and relevance to surgeons.

The Information Age has made profound changes in society and is slowly entering the healthcare field. Some of the most important areas are telemedicine, the Internet, and the world wide web (www). Millions of physicians, healthcare providers, and patients are accessing the web daily for patient information, consultation, and distant learning. Telemedicine is beginning to enter the mainstream of health care after decades of demonstration projects. There are many issues which have been raised, such as access to the information, the security of the information, and the quality of the content on the web. While telemedicine is beginning to Hower, there are numerous barriers that prevent its rapid implementation, such as licensure, reimbursement, liability, quality of service, and technical issues. In spite of the numerous challenges, telemedicine over the Internet was practiced in one of the most remote areas of the world--Mt. Everest--demonstrating that it is possible to utilize all the latest healthcare telecommunications tools in even the most extreme of settings.

Computer Security↗
PubMed1999

Teleneuropathology: a means to improve the correctness of neuropathological diagnoses in clinical practice.

Telepathology in general, and teleneuropathology in particular is the practice of pathology at a distance, viewing digitized images of histological slides on a video monitor rather than directly through a light microscope. For the transmission of the digitized images from a telemicroscope to the remote diagnostic video monitor, different technologies such as ordinary telephone lines, broadband telecommunications channels, and even the Internet can be used. The transmitted images may serve for primary neuropathological diagnosis, teleconsultation, quality assurance, proficiency testing, and distance learning. Static imaging and dynamic imaging are the two major competing technologies of telemicroscopy. Static-imaging systems appear to have levels of diagnostic accuracy that are not satisfactory for diagnostic neuropathology. In contrast, high levels of diagnostic accuracy can be achieved using dynamic-imaging systems with the transmission of live video images in real time and by using a robotized telemicroscope under the control of the remote teleneuropathologist with the possibility to examine the entire histological specimen.

Journal Article↗
PubMed1997

From Bertha Roentgen's hand to current medical imaging: one century of radiological progress.

From 1896 to 1996 radiology progressed at an amazing and unforeseen pace. The analysis of a few examples shows that these developments were due to a few groups and were enhanced by a close interaction between radiologists, physicists, engineers and manufacturers. Radiologists emphasize needs and are often able to suggest avenues for research; engineers exploit the basic discoveries of physicists and find new technologies. Manufacturers proceed from prototypes to instruments that can be built on an industrial scale at an affordable price. This system works efficiently only in a few developed countries. The gap between developing and developed countries is not narrowing and a large proportion of the world population has no access to adequate medical imaging. Very sophisticated imaging technologies used in industrialized countries are costly in terms of both money and human resources and in developing countries may usurp the limited assets that are needed for public health. Thus, the current challenge facing radiology is to take advantage of technological progress, firstly for building affordable and easy to maintain equipment giving images of sufficient quality, and secondly, through progress in telecommunications and computers, to improve medical education, telemedicine and build hospital networks. These networks will enable easier access to consultations with specialized radiologists and will give physicians the means of sharing their medical expertise. The aim is not only to narrow the gap but to provide a sufficient level of care in imaging medicine and radiotherapy throughout the world. This will only be achieved through a clear strategy and adequate human, technical and financial resources. The role of the radiological community, in particular ISR, RSNA and EAR, shall be crucial in this endeavour.

Developing Countries↗
PubMed2000

International telementoring: a feasible method of instruction.

Since the advent of improved telecommunication technology, greater bandwidth capability, medical robotics, and digital video technology, telemedicine has evolved. Telesurgical telementoring is an advanced form of telemedicine. An experienced surgeon can conduct, guide and mentor a second surgeon from a remote location. The historical method of teaching surgeons new operative techniques is exemplified in residency training: having individuals work with experienced teachers. Unfortunately, it is impractical for these specialized minimally invasive surgeons to travel and proctor generally trained surgeons each time a new surgical technique is developed. Telesurgical telementoring may represent a method to teach and mentor remote surgeons, as well as allow educational opportunities.

Education, Medical↗
PubMed1998

A novel method of surgical instruction: international telementoring.

Telemedicine is the use of communication technologies to deliver health care. Telesurgical telementoring represents an advanced form of telemedicine, whereby an experienced surgeon can guide and teach practicing surgeons new operative techniques utilizing current video technology, medical robots, and high-band-width telecommunications. This technology can potentially enhance surgeons' education, increase patients' access to experienced surgeons, and decrease the likelihood of complications due to inexperience with new techniques. A personal computer-based system was developed to immerse a surgical specialist into a distant operating room utilizing public telephone lines. Telesurgical laparoscopic telementoring has successfully been implemented in 27 prior operations between the Johns Hopkins Bayview Medical Center and the Johns Hopkins Hospital, whereby the two institutions were separated by 3.5 miles. We report our experience in performing three successful international surgical telementoring operations, one in Innsbruck, Austria, and two in Bangkok, Thailand.

Adrenalectomy↗
PubMed2003

Tele-echocardiography in paediatrics.

UNLABELLED: Echocardiographic images can be transmitted over increasing distances with less cost and better quality thanks to advances in the field of telecommunications. This technological support can be used to detect heart defects in newborns and children in remote situations. The intent of this study was to confirm the feasibility and usefulness of telemedical communication for echocardiographic evaluation of paediatric cardiovascular disease. A total of 214 echocardiographs were performed in 194 children at a remote hospital by an experienced sonographer in paediatric echocardiography. These echocardiograms were transmitted to a distant tertiary care paediatric cardiology centre using a telemedicine link across three ISDN lines. There an experienced paediatric cardiologist interpreted the tele-echocardiograms. Tele-distant diagnoses were prospectively documented and compared with the diagnoses made subsequently on direct consultation and echocardiography. The quality of transmitted echocardiographic images was sufficient for evaluation except for one case. In 191 children (98%), the remote echocardiographic diagnosis was correct as confirmed by follow-up face to face consultations. Three cases were diagnosed incorrectly. CONCLUSION: our results confirm that accurate and rapid diagnosis can be provided by tele-echocardiography in neonates and children. This facilitates the appropriate care of these patients as expensive and potentially dangerous long-distance transfers can be avoided.

Adolescent↗
PubMed1997

Telesurgical mentoring. Initial clinical experience.

BACKGROUND: Minimally invasive surgical techniques yield significant individual, economic, and social benefits when performed by experienced surgeons. Unfortunately, many of these techniques, such as laparoscopy, are associated with steep learning curves, and the incidence of complications has clearly been shown to be inversely related to experience. The initial high complication rate and the dearth of experienced endoscopic surgeons have raised concerns over training, granting of hospital privileges, and most importantly patient safety. The goal of this study was to employ current telecommunications technology in a system for the mentoring of relatively inexperienced surgeons. Therefore, we created a telesurgical system that would allow an endoscopic specialist at a central site to offer guidance and assistance to a surgeon during a laparoscopic procedure. METHODS: We developed a system that connected a central site and an operative site, a distance of approximately 3.5 miles, via a single T1 (1.54 Mbs) point-to-point communications link. The system provided real-time video display from either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, control of a robotic arm that manipulated the laparoscope, and access to electrocautery for tissue cutting or hemostasis. RESULTS: Seven patients underwent laparoscopic procedures using the telesurgical consultation system over the communications link. In all cases, the primary surgeon had limited experience with the laparoscopic approach but still had the basic skills required to obtain intraperitoneal access. All seven cases were completed successfully without complications. CONCLUSION: These initial studies have demonstrated the feasibility, effectiveness, and safety of telementoring. Telesurgical applications have the potential to greatly improve surgical education credentialing, and patient care by offering patients and their surgeons global access to surgical specialists.

Humans↗
PubMed2002

Necessary security mechanisms in a PACS DICOM access system with web technology.

The evolution in information and telecommunication technologies has allowed the development of systems that use the Internet infrastructure and Web technology to remotely access a hospital's picture archiving and communication system (PACS). However, one of the main problems in the construction of this type of system is the development of mechanisms that guarantee the security of the medical data that are being consulted. Most countries have specific norms for the protection of such medical data. This work describes security mechanisms that are developed in an access system to PACS DICOM with Web technology and comply with the Spanish legislation concerning the protection of medical data. The proposed security mechanisms are flexible, they leave room for the definition of security policies adjusted to the needs of each particular organization and they can be adapted to comply with new or foreign norms.

Computer Security↗