International telemedicine

The following is a consensus statement from the Heart Editors Action Round Table Group concerning its policy on redundant publication. This statement is being published in journals represented on the panel beginning in July, 1997.     

Ensuring the success of women in academic orthopaedics

In spring of 1995, the Academic Orthopaedic Society convened a panel of 21 female academic orthopaedists and 24 senior members of the society to discuss the challenges facing female orthopaedic residents and women in academic orthopaedics. Participants began by reviewing results of a 200 item mail survey of fulltime and parttime female academic orthopaedic surgeons. The survey had been conducted in early 1995. Using the Delphi technique, the panelists identified challenges facing women and ranked them in priority order. Although the challenges identified by survey respondents and panelists were similar, the priority assigned to them varied. Panel and survey findings pointed to a need for action in six areas: increasing mentoring; overcoming gender bias; reducing women's social and professional isolation; increasing attention to promotion and salary equity; providing greater accommodation for family responsibilities; and expanding recruitment efforts. This paper suggests actions that department chairpersons and the Academic Orthopaedic Society may take to attract more women to academic orthopaedics. Because many of the issues emerging from the survey and panel were not gender specific, implementation of the recommendations may benefit male and female orthopaedic residents and academic surgeons in general.     

Hematuria associated with low-volume cell saver in pediatric orthopaedics

Studies were performed on 89 patients with organic lesions of the nervous system in which the leading clinical symptoms consisted of paralysis and pareses. Patients received complex treatment, including pulsed magnetic fields and an electrical stimulation regime producing multilevel stimulation. A control group of 49 patients with similar conditions was included, and these patients received only sinusoidal currents. Combined treatment with magnetic and electrical stimulation was more effective, as indicated by radiographic and electromyographic investigations.     

Performance improvement in telemedicine: the essential elements

Performance improvement activities in telemedicine may be placed into five categories. (1) Licensing and credentialing. Telemedicine overcomes geographical boundaries, but its reach is constrained by state laws on licensing. Some states require a state license, whereas others grant "consultation exemptions" for out-of-state physicians. Simple renewable licenses do not guarantee quality. Potential solutions include a national telemedicine license or license reciprocity laws for telemedicine. (2) Data security and privacy. Telemedicine technology raises some security concerns. Differences in reporting requirements among states complicate the issue of privacy. Storage of telemedicine consultation records may help physicians document care decisions for risk management, but conventional long-term storage may not be feasible because of cost constraints and may not be required to document the encounter appropriately. (3) Informed consent. Potential failures in security and transmission are new, and should be communicated to the patient. (4) Peer review. Peer review findings encourage thorough, accurate, and legible documentation. Results should be recorded by provider and must be available during the recredentialing process. (5) Tailored performance improvement initiatives. By using established principles and techniques, performance improvement initiatives can gather, analyze, and communicate information about the cost-effectiveness of telemedicine. These performance improvement efforts are the heart of quality management and are critical to the justification of telemedicine. Walter Reed Telemedicine has put into effect a performance improvement plan in accordance with this outline. This article describes the plan and suggests it as a model for other telemedicine programs.     

Canada produces its first MD specializing in telemedicine

Originally Dr. Rod Elford had planned to pursue a career in sports medicine. An introduction to space medicine and the possibilities inherent in telemedicine changed all that, and last year he became the first Canadian physician to complete a clinical fellowship in this emerging field. Observers think he is likely to be the first of many.     

Low-bandwidth telemedicine for remote orthotic assessment

The 1,3-1,4-beta-glucanases from Bacillus macerans and Bacillus licheniformis, as well as related hybrid enzymes, are stable proteins comprised of one compact jellyroll domain. Their structures are studied in an effort to reveal the degree of redundancy to which the three-dimensional structure of protein domains is encoded by the amino acid sequence. For the hybrid 1,3-1,4-beta-glucanase H(A16-M), it could be shown recently that a circular permutation of the sequence giving rise to the variant cpA16M-59 is compatible with wildtype-like enzymatic activity and tertiary structure (Hahn et al., Proc. Natl. Acad. Sci. USA 91:10417-10421, 1994). Since the circular permutation yielding cpA16M-59 mimicks that found in the homologous enzyme from Fibrobacter succinogenes, the question arose whether de novo circular permutations, not guided by molecular evolution of the 1,3-1,4-beta-glucanases, could also produce proteins with native-like fold. The circularly permuted variants cpA16M-84, cpA16M-127, and cpA16M-154 were generated by PCR mutagenesis of the gene encoding H(A16-M), synthesized in Escherichia coli and shown to be active in beta-glucan hydrolysis. CpA16M-84 and cpA16M-127 were crystallized in space groups P2(1) and P1, respectively, and their crystal structures were determined at 1.80 and 2.07 A resolution. In both proteins the main parts of the beta-sheet structure remain unaffected by the circular permutation as is evident from a root-mean-square deviation of main chain atoms from the reference structure within the experimental error. The only major structural perturbation occurs near the novel chain termini in a surface loop of cpA16M-84, which becomes destabilized and rearranged. The results of this study are interpreted to show that: (1) several circular permutations in the compact jellyroll domain of the 1,3-1,4-beta-glucanases are tolerated without radical change of enzymatic activity or tertiary structure, (2) the three-dimensional structures of simple domains are encoded by the amino acid sequence with sufficient redundancy to tolerate a change in the sequential order of secondary structure elements along the sequence, and (3) the native N-terminal region is not needed to guide the folding polypeptide chain toward its native conformation.     

Successful development of telemedicine systems--seven core principles

This article discusses seven core principles that underlie the development of successful telemedicine systems. These principles have been formulated from evidence in the literature and from the personal experience of setting up three telemedicine systems in Australia. Of particular importance has been the observation of failed telemedicine systems, of which there are many examples in the world literature. It is important to learn from history by studying both the successful and the unsuccessful components of these programmes. Telemedicine is still a relatively new area of interest, and while the technology is rapidly evolving, changing and fascinating, it is still the human factors that tend to determine the success or failure of telemedicine projects. These cannot be ignored.     

Consumer satisfaction with telemedicine child psychiatry consultation in rural Kentucky

Forty-three rural Kentucky families who obtained child psychiatry consultation during the initial eight months of the University of Kentucky's telemedicine program completed questionnaires assessing their satisfaction with telemedicine. Respondents were 46 parents and nine children. All respondents reported that they were very satisfied with the consultation; all of the children and 98 percent of the parents reported that they were as satisfied with the telemedicine consultation as with an in-person visit. Few respondents reported nervousness about using the equipment. These results suggest that child psychiatry consultation via telemedicine provides high levels of satisfaction for both children and adults.     

Planning criteria for multicentre, multilingual telemedicine conferences

The international telemedicine conference Chinese TeleMed 96 was held in November 1996. This three-way teleconference included delegates in London (where the international telemedicine conference TeleMed 96 was taking place) and medical staff from one Beijing hospital and one Hong Kong medical faculty. In total, over 1000 health-care personnel across eight time-zones participated. The event demonstrated that the quality of teleconferencing technology was suitable for medical teaching, for providing medical consultations to remote locations and for stimulating medical exchanges. In general, planning a telemedicine conference requires a longer lead time, a wider representation of expertise in the organizing committee and more financial resources than conventional conferences. It is recommended that the aim and format of a telemedicine conference be determined at least one year before the target date. Criteria for improving the preparation of such conferences have been identified and a set of guidelines for future conference organizers has been drawn up.     

Early experience using telemedicine for neonatal surgical consultations

BACKGROUND/PURPOSE: Telemedicine affords the opportunity to extend the presence of surgical evaluation to centers without an on-site pediatric surgeon. However, concern for cost, accuracy of diagnosis, and physician acceptance have limited its use. METHODS: Using a low-cost, desktop computer-based system, this study was designed to test the effectiveness of telemedicine in neonatal surgical consultation. RESULTS: Early experience with six video-teleconference (VTC) and six store-and-forward consultations are presented. Diagnosis was established accurately in all cases. With the three intestinal cases (jejunal atresia, duplication cyst, and r/o malrotation), diagnostic studies were guided by the images transmitted with the consult. Earlier care could be implemented in other cases. Technical problems were encountered primarily with the VTC modality, which also proved more consuming of physician time. CONCLUSIONS: Telemedicine was used successfully in each case and proved accurate in diagnosis and guiding further evaluation. This is the first report of the use of telemedicine for surgical consultation in the intensive care nursery.     

A framework for the economic evaluation of telemedicine

Alongitudinal study was conducted in four indicator villages of PHC Shankargarh, District Allahabad, U.P. from July 1991 to June 1992 to have information on seasonality of indoor resting anopheline species in silica sand/hard stone quarry area. Fourteen anopheline species namely, An. aconitus (0.35%), An. annularis (17.03%), An. barbirostris (0.09%), An. culicifacies (36.74%), An. fluviatilis (0.13%), An. nigerrimus (0.01%), An. pallidus (4.40%), An. splendidus (0.02%), An. stephensi (0.01%), An. subpictus (40.84%), An. tessellatus (0.15%), An. turkhudi (0.004%), An. vagus (0.20%) and An. varuna (0.02%) were collected. An. culicifacies, An. subpictus and An. annularis were found throughout the year. An. fluviatilis, An. pallidus, An. vagus and An. aconitus were also observed in all the seasons except extreme summer. However, An. barbirostris and An. splendidus were collected only in monsoon/post-monsoon and winter seasons. An. tessellatus and An. stephensi were recorded in winter and spring seasons. An. nigerrimus and An. varuna were recorded in winter, while An. turkhudi in spring. Prolonged high vector density may be attributed to the extended malaria transmission in this area.     

Collaborative problem-solving in telemedicine and evidence interpretation in a complex clinical case

The objective of this study was to evaluate the effect of different infection levels of Ostertagia ostertagi and Cooperia oncophora in a simulated 'first grazing season' on the resistance of calves to an artificial challenge infection. The infection levels were determined by the infection schedules and the chemoprophylaxis used. Thirty six 7-11-month old Holstein-Friesian bull calves were randomly divided into four groups. The animals of group B received an ivermectin sustained release bolus (ISRB) on day 0. The calves of group D were treated on days 0 and 56 with a subcutaneous injection of doramectin (0.2 mg kg(-1) BW). Group C was the untreated control group. The calves of group N were used as helminth-naive controls, while the animals of groups B, C and D were trickle infected for 24 weeks. The infection schedules were designed to simulate the expected infection pattern for each treatment group under set-stocked conditions in temperate climate areas. After the last infection, all animals were treated with oxfendazole. One week later, all animals received a challenge infection of 50,000 O. ostertagi L3 and 100,000 C. oncophora L3, spread over 10 consecutive days. During the primary infection period the faecal egg output and the serum pepsinogen and antibody levels reflected the different levels of host-parasite contact between the groups (group C > group D > group B > group N). After the challenge infection, faecal egg counts, total Ostertagia burden, size of the adult worms and abomasal globule leucocyte counts all indicated a positive relationship between the level of Ostertagia infection during the primary infection period and the level of acquired resistance. A reduction of host-parasite contact during the primary infection period, as a consequence of the infection schedule and the chemoprophylaxis used, resulted in a diminished level of resistance to the artificial challenge infection with O. ostertagi. Faecal cultures and small intestine worm counts indicated that all previously infected groups had acquired a high degree of resistance to the Cooperia challenge infection.     

Decentralized special training in pulmonary medicine. A project using telemedicine

In arctic Norway, where there is a lack of specialists in pulmonary medicine two postgraduate students, already qualified as specialists in internal medicine at Troms? Regional Hospital, applied to continue their training at their respective local hospitals. The regional hospital in Troms? has a long tradition of telemedicine, with network links to local hospitals in the region, and is equipped for interactive consultation and the bilateral transmission of x-rays and video recordings, and digital transmission of x-rays. Accordingly, supported by their supervisor, the two postgraduate students applied to the committee for postgraduate education in pulmonary medicine to have a year's work at their respective local hospitals, supervised via the telemedicine facilities, accepted as equivalent to a six-month module of the normal syllabus. The project was approved and executed as planned. The registrars, who were responsible for pulmonary service at their local hospitals, served four days a month at the regional hospital, and their supervisor visited the local hospitals one day each month. All internal education at the regional hospital was made available by means of a weekly interactive televised link-up, x-rays being displayed on screen as transmitted digitally; bronchoscopies were shown by video, and ad hoc tutorials arranged as needed. Evaluated by the national committee, the project was found satisfactory, and the registrars were duly qualified.