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The Spacebridge to Russia Project: internet-based telemedicine.

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

Computer Systems↗

Computerized training in breast self-examination: a test in a community health center.

Fifty-eight women recruited from a community health center completed either a brief interactive multimedia training program on breast self-examination using a breast model and computer guided feedback on accuracy of lump detection or read a National Cancer Institute pamphlet on breast self-examination and breast lumps. Women using the computer program as compared to the pamphlet group reported a higher sense of self-efficacy for being able to perform a breast self-examination immediately after their educational session and 1 month later. However, the increase in self-efficacy for the computer group diminished over 4 weeks, underscoring the importance of an environment that reminds and reinforces learning for women about the performance of regular breast self-examination. The increase in sense of self-efficacy to perform breast self-examination with roughly 20 minutes of computer-based training and the partial maintenance of that self-efficacy 30 days later suggests the utility of incorporating short, focused interventions in busy primary healthcare settings.

Adult↗

Effectiveness of a tailored intervention to increase factory workers' use of hearing protection.

BACKGROUND: In the United States it is estimated that more than 30 million workers are exposed to harmful levels of noise on the job. When engineering or administrative controls cannot be used to reduce noise, workers should always use hearing protection devices (HPDs) when exposed to loud noise to prevent noise-induced hearing loss (NIHL). Previous research has shown that workers do not always use HPDs when required; therefore, it is essential that workers assume personal responsibility for preventing NIHL by increasing their use of HPDs. OBJECTIVES: This study tested the effectiveness of an individually tailored multimedia intervention to increase use of HPDs by factory workers. METHODS: A randomized controlled design was used to compare the effects of a tailored intervention (n= 446) with two other interventions (a nontailored predictor-based intervention (n= 447) and a control intervention (n= 432)) on workers' self-reported use of HPDs 6 to 18 months following the intervention. RESULTS: Only those workers receiving the tailored intervention significantly increased their use of HPDs from pretest to posttest. However, this increase significantly differed from the nontailored group but not from the control group. CONCLUSIONS: Individually-tailored interventions offer promise for changing behavior. In light of the similarity between the results for the tailored intervention and the control intervention groups, further research is needed to understand barriers to HPD use and how to maximize the benefits of individually tailored interventions in this setting.

Adult↗

Effects of booster interventions on factory workers' use of hearing protection.

BACKGROUND: The provision of reinforcements or boosters to interventions is seen as a logical approach to enhancing or maintaining desired behavior. Empirical studies, however, have not confirmed the effectiveness of boosters nor assessed the optimum number of boosters or the timing for their delivery. OBJECTIVES: This randomized controlled trial contrasted the effect of four booster conditions (a). 30 days; (b). 90 days; (c). 30 and at 90 days; and (d). no boosters of the intervention to increase the use of hearing protection devices (HPDs). METHODS: A total of 1325 factory workers completed a computerized questionnaire and were randomly assigned to one of three computer-based (tailored, nontailored predictor-based, or control) multimedia interventions designed to increase the use of hearing protection devices. After the intervention, colorful boosters specific to the type of training received were mailed to workers' homes. Posttest measures of use were administered at the time of their next annual audiogram 6 to 18 months after the intervention. RESULTS Repeated measures of analysis of variance (ANOVA) showed a significant main effect for the booster (after 30 days) in the group that received tailored training (F[3442] = 2.722; p =.04). However, in the assessment of the interaction between time (pretest and posttest) and boosters (four groups), the ANOVA did not find significant differences in hearing protection device use for any of the training groups. To assess for significant differences between groups, post hoc comparisons were conducted at the pretest and posttest for the total sample and for the subsample of workers who reported using hearing protection devices less than 100% of the time needed. Sheffé contrasts by intervention group, gender, ethnicity, and hearing ability found no significant changes in the mean use of hearing protection devices for the booster groups. CONCLUSIONS: Although the provision of boosters represented a considerable commitment of resources, their use was not effective in this study. However, it would be premature to eliminate boosters of interventions. Further study is needed to explore the effects of different booster types for increasing the use of hearing protection devices, and to assess carefully the effects of boosters on other health behaviors in studies with controlled designs.

Adult↗

Effects of enhanced patient education on compliance with silicone gel sheeting and burn scar outcome: a randomized prospective study.

The purpose of this study was to determine whether enhanced patient education increases compliance with silicone gel sheeting (SGS) on hypertrophic (HT) scars and to determine whether this results in any improvement in scar outcome. Outpatients with a HT burn scar were randomized to either a conventional education group (CEG), which received routine instruction on the use of SGS or to an enhanced education Group (EEG), which also received routine instruction, along with a detailed 5-page handout and a 26-minute videotape. The CEG (n = 12, 67% male, age 38 +/- 10 years) and the EEG (n = 13, 77% male, age 47 +/- 10 years) were followed monthly for 6 months. Subjects in the EEG wore SGS for 21.8 +/- 3.0 hr/day compared with only 10.1 +/- 7.5 hr/day of use in the CEG (P <.001). Scars in the EEG had significantly better Vancouver Scar Scale ratings for pigmentation (P =.02), height (P =.03), and pliability (P =.02) by 6 months. Patients in the EEG had significantly better subjective ratings for the parameters of scar itch (P =.01), color (P =.02), hardness (P =.01), and elevation (P =.01). Finally, scars in the EEG had significantly better ratings for border height (P =.002) and thickness (P =.01) at 6 months based on evaluation of digital photographs. Detailed multimedia patient education improves compliance with SGS and results in a better scar outcome.

Adult↗

Digital tools for collecting data from cervigrams for research and training in colposcopy.

Colposcopy is a critical part of gynecologic practice but has documented deficiencies, including lack of correlation between the colposcopic appearance and the severity of underlying neoplasia, limited reproducibility, and difficulty in the optimal placement of colposcopically directed biopsies. In a collaborative effort to improve colposcopy, we are analyzing digitized cervigram images from National Cancer Institute-funded studies. Specifically, the National Cancer Institute has collected close to 100,000 cervigrams, digitized to create a database of images of the uterine cervix for research, training, and education. In addition to the cervigram images, this database contains clinical, cytologic, and molecular information at multiple examinations of 15,000 women, with password and ID labeling strategies to protect patient privacy. The National Library of Medicine has designed two web-accessible software tools. The Boundary Marking Tool allows experts on colposcopy to perform an evaluation of the pictures and to mark boundary regions of normal and abnormal regions of the uterine cervix; these evaluations are collected and saved in the database. The Multimedia Database Tool enables retrieval of test and image biomedical data according to specific queries, for example, all women with cervical intraepithelial neoplasia 3 whose cytologic results are atypical squamous cells of undetermined significance. The resource soon will be available as an open resource, via a teaching tool coordinated by a database manager, which will permit a variety of applications for teaching and research. In this article, we describe the perceived need for the resource and its components.

Biomedical Research↗

Advanced technologies in plastic surgery: how new innovations can improve our training and practice.

Over the last two decades, virtual reality, haptics, simulators, robotics, and other "advanced technologies" have emerged as important innovations in medical learning and practice. Reports on simulator applications in medicine now appear regularly in the medical, computer science, engineering, and popular literature. The goal of this article is to review the emerging intersection between advanced technologies and surgery and how new technology is being utilized in several surgical fields, particularly plastic surgery. The authors also discuss how plastic and reconstructive surgeons can benefit by working to further the development of multimedia and simulated environment technologies in surgical practice and training.

Case Management↗

E-learning: Web-based education.

PURPOSE OF REVIEW: This review introduces state-of-the-art Web-based education and shows how the e-learning model can be applied to an anaesthesia department using Open Source solutions, as well as lifelong learning programs, which is happening in several European research projects. RECENT FINDINGS: The definition of the term e-learning is still a work in progress due to the fact that technologies are evolving every day and it is difficult to improve teaching methodologies or to adapt traditional methods to a new or already existing educational model. The European Community is funding several research projects to define the new common market place for tomorrow's educational system; this is leading to new frontiers like virtual Erasmus inter-exchange programs based on e-learning. SUMMARY: The first step when adapting a course to e-learning is to re-define the educational/learning model adopted: cooperative learning and tutoring are the two key concepts. This means that traditional lecture notes, books and exercises are no longer effective; teaching files must use rich multimedia content and have to be developed using the new media. This can lead to several pitfalls that can be avoided with an accurate design phase.

Anesthesiology↗

An open medical imaging workstation architecture for platform-independent 3-D medical image processing and visualization.

A need for an entirely new medical workstation design was identified to increase the deployment of 3-D medical imaging and multimedia communication. Recent wide acceptance of the Word Wide Web (WWW) as a general communication service within the global network has shown how big the impact of standards and open systems can be. Information is shared among heterogeneous systems and diverse applications on various hardware platforms only by agreeing on a common format for information distribution. For medical image communications, the Digital Imaging and Communication in Medicine (DICOM) standard is possibly anticipating such a role. Logically, the next step is open software: platform-independent tools, which can as easily be transferred and used on multiple platforms. Application of the platform-independent programming language Java enables creation of plug-in tools, which can easily extend the basic system. Performance problems inherent to all interpreter systems can be circumvented by using a hybrid approach. Computationally intensive functions like image processing functions can be integrated into a natively implemented optimized image processing kernel. Plug-in tools implemented in Java can utilize the kernel functions via a Java-wrapper library. This approach is comparable to the implementation of computationally intensive operations in hardware.

Computer Communication Networks↗

Asynchronous web-based patient-centered home telemedicine system.

A web-based system for asynchronous multimedia messaging between shoulder replacement surgery patients at home and their surgeons was developed and tested. A web browser plug-in simplifies the process of capturing video and transferring it to a web site for novice computer users. The design of the video capture plug-in can be reused to acquire and securely transfer any type of data over the web. For example, readings from home biosensor instruments (e.g., glucometers and spirometers) that can be connected to a personal computer can be transferred to a home telemedicine web site. Both patients and doctors can access this web site to monitor health status longitudinally. Six patients, whose familiarity with computers ranged from no experience to expert users, used the system. All of the subjects were able to use the system to check treatment reminders and to send at least one message with video to their surgeons. The surgeons monitored the system regularly and always responded to messages within 24 h during the six-month trial period.

Arthroplasty, Replacement↗

Using 3D computer simulations to enhance ophthalmic training.

PURPOSE: To develop more effective methods of demonstrating and teaching complex topics in ophthalmology with the use of computer aided three-dimensional (3D) animation and interactive multimedia technologies. METHODS: We created 3D animations and interactive computer programmes demonstrating the neuroophthalmological nature of the oculomotor system, including the anatomy, physiology and pathophysiology of the extra-ocular eye muscles and the oculomotor cranial nerves, as well as pupillary symptoms of neurological diseases. At the University of Vienna we compared their teaching effectiveness to conventional teaching methods in a comparative study involving 100 medical students, a multiple choice exam and a survey. RESULTS: The comparative study showed that our students achieved significantly better test results (80%) than the control group (63%) (diff. = 17 +/- 5%, p = 0.004). The survey showed a positive reaction to the software and a strong preference to have more subjects and techniques demonstrated in this fashion. CONCLUSION: Three-dimensional computer animation technology can significantly increase the quality and efficiency of the education and demonstration of complex topics in ophthalmology.

Computer Simulation↗

Automated computer interviews to elicit utilities: potential applications in the treatment of deep venous thrombosis.

OBJECTIVE: To assess the practicality of an automated computer interview as a method to assess preferences for use in decision making. To assess preferences for outcomes of deep vein thrombosis (DVT) and its treatment. STUDY DESIGN: A multimedia program was developed to train subjects in the use of different preference assessment methods, presented descriptions of mild post-thrombotic syndrome (PTS), severe PTS and stroke and elicited subject preferences for these health states. This instrument was used to measure preferences in 30 community volunteers and 30 internal medicine physicians. We then assessed the validity of subject responses and calculated the number of quality-adjusted life years (QALYs) for each individual for each alternative. RESULTS: All subjects completed the computerized survey instrument without assistance. Subjects generally responded positively to the program, with volunteers and physicians reporting similar preferences. Approximately 26.5% of volunteers and physicians had preferences that would be consistent with the use of thrombolysis. Individualization of therapy would lead to the most QALYs. CONCLUSIONS: Utilization of computerized survey instruments to elicit patient preferences appears to be a practical and valid approach to individualize therapy. Application of this method suggests that there may be many patients with DVT for whom treatment with a thrombolytic drug would be optimal.

Adult↗

Problem-oriented prefetching for an integrated clinical imaging workstation.

Prefetching methods have traditionally been used to restore archived images from picture archiving and communication systems to diagnostic imaging workstations prior to anticipated need, facilitating timely comparison of historical studies and patient management. The authors describe a problem-oriented prefetching scheme, detailing 1) a mechanism supporting selection of patients for prefetching via characterizations of clinical problems, using multiple data sources (picture archiving and communication systems, hospital information systems, and radiology information systems), classifying patients into cohorts on the basis of their medical conditions (e.g., lung cancer); and 2) prefetching of multimedia data (imaging, laboratory, and medical reports) from clinical databases to enable the viewing of an integrated patient record. Preliminary evaluation of the prefetching algorithm using classic information retrieval measures showed that the system had high recall (100 percent), correctly identifying and retrieving data for all patients belonging to a target cohort, but low precision (50 percent). A key finding during testing was that the recall of the system was increased through the use of multiple data sources (compared with one data source), because of better patient descriptors. Medical problems and patient cohorts were more specifically defined by combining information from heterogeneous databases.

Algorithms↗

Generation and evaluation of intraoperative inferences for automated health care briefings on patient status after bypass surgery.

OBJECTIVE: The authors present a system that scans electronic records from cardiac surgery and uses inference rules to identify and classify abnormal events (e.g., hypertension) that may occur during critical surgical points (e.g., start of bypass). This vital information is used as the content of automatically generated briefings designed by MAGIC, a multimedia system that they are developing to brief intensive care unit clinicians on patient status after cardiac surgery. By recognizing patterns in the patient record, inferences concisely summarize detailed patient data. DESIGN: The authors present the development of inference rules that identify important information about patient status and describe their implementation and an experiment they carried out to validate their correctness. The data for a set of 24 patients were analyzed independently by the system and by 46 physicians. MEASUREMENTS: The authors measured accuracy, specificity, and sensitivity by comparing system inferences against physician judgments, in cases where all three physicians agreed and against the majority opinion in all cases. RESULTS: For laboratory inferences, evaluation shows that the system has an average accuracy of 98 percent (full agreement) and 96 percent (majority model). An analysis of interrater agreement, however, showed that physicians do not agree on abnormal hemodynamic events and could not serve as a gold standard for evaluating hemodynamic events. Analysis of discrepancies reveals possibilities for system improvement and causes of physician disagreement. CONCLUSIONS: This evaluation shows that the laboratory inferences of the system have high accuracy. The lack of agreement among physicians highlights the need for an objective quality-assurance tool for hemodynamic inferences. The system provides such a tool by implementing inferencing procedures established in the literature.

Coronary Artery Bypass↗

A DBMS-based medical teleconferencing system.

This article presents the design of a medical teleconferencing system that is integrated with a multimedia patient database and incorporates easy-to-use tools and functions to effectively support collaborative work between physicians in remote locations. The design provides a virtual workspace that allows physicians to collectively view various kinds of patient data. By integrating the teleconferencing function into this workspace, physicians are able to conduct conferences using the same interface and have real-time access to the database during conference sessions. The authors have implemented a prototype based on this design. The prototype uses a high-speed network test bed and a manually created substitute for the integrated patient database.

Computer Graphics↗

Information technology in medical education: current and future applications.

Information technology has the potential to revolutionise the way medicine is learned by students and healthcare professionals. This potential was recognised by the General Medical Council in their 1993 report Tomorrow's doctors in which the need for future generations of doctors to be familiar with the application and scope of information technology is described. This paper focuses on the use of computers as aids to learning medicine and discusses two key applications of information technology to medical education: multimedia and the internet. The current use and potential for these areas of information technology are described and future developments discussed.

Adult↗

Structured entry of radiology reports using World Wide Web technology.

Structured data entry--in which information is entered by using predetermined data elements and formats--has the potential to improve the radiology reporting process. The dependence on particular computer hardware and software platforms has posed a barrier to wider use of this approach. The World Wide Web (WWW), a client-server protocol for delivery of multimedia data via the Internet, was used to achieve platform-independent structured entry of radiology reports. A developmental system for structured entry of radiology reports, called SPIDER, incorporates a knowledge base of hierarchically organized concepts, a WWW server, and two specialized programs. The WebForm program transforms the system's knowledge into graphical WWW data-entry forms; the WebReport program converts data entered on these forms into outline-format reports. SPIDER received favorable evaluations from sonographers and physicians who used the system to record the results of several test cases. WWW technology can be used to achieve platform-independent entry of the results of radiologic procedures.

Artificial Intelligence↗

Radiology Cases in Pediatric Emergency Medicine: amplifying the benefits of performance improvement by sharing a hospital performance improvement program with the world via the Internet.

A hospital performance improvement project to improve the quality of x-ray interpretations in the emergency department is described. To amplify the benefits of this project, a multimedia computer program containing this information was created and distributed via the mail and over the internet. Users are encouraged to copy the program disks and distribute them to others (no fees or royalties). The advantages of this method over conventional journals in print are described. Successful distribution of this program, known as Radiology Cases in Pediatric Emergency Medicine (RCPEM), and positive feedback from users, stimulated the continuation of this project, which has now released its fifth volume with two more volumes planned. RCPEM (a hospital performance improvement project) now continues to expand as the knowledge gained is disseminated over the internet to improve the quality of care rendered to children all over the world. Amplifying the benefits of other performance improvement projects can be done in a similar manner.

Computer Communication Networks↗