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					   TELEPATHOLOGY
THROUGH THE INTERNET
        Carlo Alberto Beltrami

  Dept. of Pathology, University of Udine, Italy;
       TELEPATHOLOGY
 Is the practice of Pathology at distance
 The visual information managed by the
  pathologist is peculiar: no knowledge
  about number and characteristics of
  images is available a priori
 As a consequence, telepathology has
  grown less rapidly than other specialities
  (e.g. teleradiology)
    TELEPATHOLOGY
      Applications

 Remote Consultation
 Distant Intraoperative Diagnostic
  Service
 DistributedReference Case Archive
 Remote Morphometry Lab
 Quality Assessment
   REMOTE DIAGNOSIS

 Static   telepathology on selected images

 Dynamic     telepathology guided by local
                   pathologist

 Dynamic-robotic    real-time telepathology
INTERNET                TELEMEDICINE

   management of        Management of a
    information           particular type of
                          medical information
   cooperation among    cooperation among
    workgroups            medical professionals
     TELEPATHOLOGY
    Remote Consultation
 Aid in solving difficult diagnostic
  problems by sending the cases to
  (distant) expert pathologists
 usually carried out by using mail or
  courier
 no need for realtime
    TELEPATHOLOGY
    BASIC REQUIREMENTS:
 Simpleness


 Thrift


   Rapidity
    REMOTE CONSULTATION
        ON INTERNET
 Realised through Internet Electronic
  Mail with MIME extension
 Asynchronous process: sender and
  recipient interact only with the local mail
  server through SMTP and POP
 no real-time
 It is possible to easily carry out multiple
  consultations
INTERNET ELECTRONIC MAIL
 Protocol for exchange of text messages
 Client/Server paradigm
 It is composed by:
  – definition of the message format [RFC822]
  – definition of the communication protocol
    (SMTP, Simple Mail Transfer Protocol)
    [RFC821]
           protocol for reading e-mail:
 Additional
 POP (Post Office Protocol) [RFC1725]
MULTIMEDIA ELECTRONIC MAIL
 Exchange   of multimedia messages:
  Multipurpose Internet Mail Extension
  [RFC1521-1522]
 Extension of e-mail protocol, backward
  compatible
 text, sounds, images, movies using
  standard e-mail infrastructures
TELEPATHOLOGY
  ON INTERNET
   REMOTE CONSULTATION
       ON INTERNET
  We tested the suitability of multimedia
  electronic mail for remote consultation
         by evaluating the accuracy
    of the remote diagnosis performed
      on hypermedia histologic cases
        of gastrointestinal pathology
USING ALREADY AVAILABLE HW&SW
             MATERIAL:
     Telepathology workstations
          UDINE                        TRENTO
   HARDWARE:                    HARDWARE:
    Macintosh IIFx, NuVista       Leitz Quantimet, HP700
    framegrabber, Sony
    3CCD, Zeiss Axiophot
   MAIL CLIENT:                 MAIL CLIENT:
    Eudora v1.5.1                 elmv2.3.7, with mpack1.4
                                  for MIME encoding
    THE TWO LOCATIONS


             Trento
                      Udine



NORTH-EAST               - 160 km
  ITALY
                           (300 km)
    Telepathology using Internet
     Multimedia Electronic Mail:
      Remote Consultation on
     Gastrointestinal Pathology.
Della Mea V, Forti S, Puglisi F, Bellutta P, Finato
     N, Dalla Palma P, Mauri F, Beltrami CA.
  Journal of Telemedicine and Telecare 1996;
                      2:28-34
       MATERIAL: Cases
 58 consecutive cases of gastrointestinal
  pathology (gastritis, carcinoma,
  lymphoma, others)
 Gold standard: local diagnosis, obtained
  directly through the microscope
 Selection of representative images
 Transmission of images and brief clinical
  history using e-mail
       MATERIALS: Images
 Udine: 640x480, RGB 24bit (900 Kb);
 Trento: 512x512, RGB 24bit (786 Kb);


   JPEG compression (lossy method with
    variable compression levels
    corresponding to variable quality):
    15:1 ratio after some test
       RESULTS: Images
 Observed compression rates: 6:1-40:1
 File dimensions: 18-158 Kbytes
 Different stainings ->
  different compression
  (e.g. mod.Giemsa images: greater ratios)
        RESULTS: Cases
 Each case required an average of 5.9
  (2-11) images
 Average time needed for transmission:
  about 25 minutes, depending on network
  traffic and number of delivered images
  (not so important in this approach)
         RESULTS: Diagnosis
   The overall agreement was reached in 50 out
    of 58 cases:

    Agreement=86%, K-statistic=0.835, p<0.001

   2 cases: insufficient images for a diagnosis
      Expert consultation in
      Pathology through the
  Internet: melanoma vs benign
       melanocytic tumours.

Della Mea V, Puglisi F, Forti S, Delendi M, Boi
    S, Mauri F, Dalla Palma P, Beltrami CA.
      J.Telemedicine and Telecare 1997; 3
                (Suppl.1):17-19.
Methods: statistical evaluation


 The chance-corrected agreement
 between local and remote diagnosis
 is assessed by the k-statistic.
                 Results: diagnoses
   local pathologist: 6 malignant lesions, 14 benign;
   remote pathologist: 9 malignant lesions, 10 benign, 1
    insufficient.

   Agreement: 78.95%, k=0.58, p<0.002

   Remote diagnosis on the specimens: remote pathologist agreed
    with all but two local diagnoses:
     – benign lesion instead of malignant lentigo,
     – melanoma instead of Spitz nevus
              Results: images
           5.3±1.3 images per case
           56.2±34.5 Kbytes per
            image
            (compression ratio
            13.7:1)
           298±185 Kbytes per case

Without JPEG compression, a similar case
would use 4.07 Mbytes; thus compressed cases
are 7.3% of uncompressed ones, and this reduces
transmission time of 92.7%.
Fine needle aspiration cytology of
the breast: a preliminary report on
  telepathology through Internet
    multimedia electronic mail

    Della Mea V, Puglisi F, Bonzanini S,
       Forti S, Amoroso V, Visentin R,
         Dalla Palma P, Beltrami CA
    Modern Pathology 1997; 10:636-641.
        Materials and Methods

 N° of cases (FNAB): 49
 Local diagnosis (through the microscope)
 Selection of the representative images
 Acquisition and compression
 Transmission by e-mail (Internet)
 Remote diagnosis
 Validation of the results
    Materials and Methods
           Validation of the results



       Golden standard: histology

 Chance-corrected agreement: k-statistic
 Sensitivity, specificity, positive predictive
  value, negative predictive value, efficacy.
      Materials and Methods
                    Images

Mail agent: Pathmail v0.62 (Eudora light)

   Acquisition: 640 x 480 pixels

   JPEG format

   Compression ratio: 25 : 1
                 Results
                  Images
 Total:   137 images

 Average:   2.8 images/case

 Volume/image:    mean 35
 Kbytes/image
                  Images
    Comparison between breast cytology and
          gastrointestinal pathology


                   Breast           Gastrointestal
                   cytology         pathology
N° images/case          2.8                 4.5
Volume/image            35 Kbytes           54.9
Kbytes
Volume/case             98 Kbytes           248
Kbytes
         Results
Diagnostic agreement
          local vs remote
   81.6% (k=0.63, p < 0.001)
        local vs histology*
   84.2% (k=0.66, p < 0.001)
remote (telecytology) vs histology*
   81.6% (k=0.61, p < 0.001)
                          *histology: 37/49
                          cases
                Results
                    Local   Remote
Sensitivity (%TP)   87.5       83.3
Specificity (%TN)   83.3       81.8
Pos Pred Value      91.3       90.9
Neg Pred Value      76.9       69.2
Efficacy            86.1       82.8
               Conclusions
A good agreement between local and remote
pathologists seems to be obtainable on cytological
diagnoses of breast lesions by using Internet e-
mail for telecytology purposes

                                           OK
Telepathology for frozen sections
  150 consecutive cases
  3 different local pathologists with
   different experience
  evaluation of acquisition and
   transmission times
  evaluation of diagnostic validity
Telepathology for frozen sections
       preliminary results
  acquisition time: acceptable (4
   minutes/case)
  diagnostic validity: 96.7%
  no significant differences among
   differently skewed pathologists
  No stable performance of the Internet (18
   minutes, up to 3 hours)
               Conclusions
Internet e-mail is a low-cost telepathology tool that
does not force pathologists to use new machines or
new technological products as often occurs when
informatics meets medicine.

                                            The
                                            End
                   Current Status
         Tolmezzo
                           Gemona
                                         An.Pathology
                                          Radiology
 S.Daniele                                   Labs
                                         Surgical Dept.
                                              etc.
                              Cividale
                   Udine


Vito                           Palmanova
                               Frozen Sections
        Latisana
                               Consultation
    The Italian Telepathology
             Network
 Udine, Verona, Milano, Ferrara, Ancona,
  Bari, Messina, Sassari
 telediagnosis, telequantitation, distant
  teaching, quality control
 Due to start in 1998
    TELEPATHOLOGY
  BASIC REQUIREMENTS:
• Simpleness
• Inexpensiveness
• Quickness

				
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posted:10/3/2011
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