Elizabeth A. Krupinski

Overview of telepathology, virtual microscopy, and whole slide imaging: prospects for the future ☆

Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. Today, fourth-generation telepathology systems, so-called virtual slide telepathology systems, are being used for education applications. Both conventional and innovative surgical pathology diagnostic services are being designed and implemented as well. The technology has been commercialized by more than 30 companies in Asia, the United States, and Europe. Early adopters of telepathology have been laboratories with special challenges in providing anatomic pathology services, ranging from the need to provide anatomic pathology services at great distances to the use of the technology to increase efficiency of services between hospitals less than a mile apart. As to what often happens in medicine, early adopters of new technologies are professionals who create model programs that are successful and then stimulate the creation of infrastructure (ie, reimbursement, telecommunications, information technologies, and so on) that forms the platforms for entry of later, mainstream, adopters. The trend at medical schools, in the United States, is to go entirely digital for their pathology courses, discarding their student light microscopes, and building virtual slide laboratories. This may create a generation of pathology trainees who prefer digital pathology imaging over the traditional hands-on light microscopy. The creation of standards for virtual slide telepathology is early in its development but accelerating. The field of telepathology has now reached a tipping point at which major corporations now investing in the technology will insist that standards be created for pathology digital imaging as a value added business proposition. A key to success in teleradiology, already a growth industry, has been the implementation of standards for digital radiology imaging. Telepathology is already the enabling technology for new, innovative laboratory services. Examples include STAT QA surgical pathology second opinions at a distance and a telehealth-enabled rapid breast care service. The innovative bundling of telemammography, telepathology, and teleoncology services may represent a new paradigm in breast care that helps address the serious issue of fragmentation of breast cancer care in the United States and elsewhere. Legal and regulatory issues in telepathology are being addressed and are regarded as a potential catalyst for the next wave of telepathology advances, applications, and implementations.

MR imaging of arrhythmogenic right ventricular cardiomyopathy: Morphologic findings and interobserver reliability

Background: Magnetic resonance (MR) imaging is frequently used to diagnose arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). However, the reliability of various MR imaging features for diagnosing ARVC/D is unknown. The purpose of this study was to determine which morphologic MR imaging features have the greatest interobserver reliability for diagnosing ARVC/D. Methods: Forty-five sets of films of cardiac MR images were sent to 8 radiologists and 5 cardiologists with experience in this field. There were 7 cases of definite ARVC/D as defined by the Task Force criteria. Six cases were controls. The remaining 32 cases had MR imaging because of clinical suspicion of ARVC/D. Readers evaluated the images for the presence of (a) right ventricle (RV) enlargement, (b) RV abnormal morphology, (c) left ventricle enlargement, (d) presence of high T1 signal (fat) in the myocardium, and (e) location of high T1 signal (fat) on a Likert scale with formatted responses. Results: Readers indicated that the Task Force ARVC/D cases had significantly more (χ2 = 119.93, d.f. = 10, p < 0.0001) RV chamber size enlargement (58%) than either the suspected ARVC/D (12%) or no ARVC/D (14%) cases. When readers reported the RV chamber size as enlarged they were significantly more likely to report the case as ARVC/D present (χ2= 33.98, d.f. = 1, p < 0.0001). When readers reported the morphology as abnormal they were more likely to diagnose the case as ARVC/D present (χ2 = 78.4, d.f. = 1, p < 0.0001), and the Task Force ARVC/D (47%) cases received significantly more abnormal reports than either suspected ARVC/D (20%) or non-ARVC/D (15%) cases. There was no significant difference between patient groups in the reported presence of high signal intensity (fat) in the RV (χ2 = 0.9, d.f. = 2, p > 0.05). Conclusions: Reviewers found that the size and shape of abnormalities in the RV are key MR imaging discriminates of ARVD. Subsequent protocol development and multicenter trials need to address these parameters. Essential steps in improving accuracy and reducing variability include a standardized acquisition protocol and standardized analysis with dynamic cine review of regional RV function and quantification of RV and left ventricle volumes.

Visual scanning patterns of radiologists searching mammograms

RATIONALE AND OBJECTIVES I examined whether the principles of search, detection, and decision making described for pulmonary nodule detection can be applied to lesion detection in mammographic images. METHODS The eye position of six radiologists (three staff mammographers and three radiology residents) was recorded as they searched mammograms for masses and microcalcifications. RESULTS True- and false-positive decisions were associated with prolonged gaze durations; false-negative decisions were associated with longer gaze durations than true-negatives. Readers with more experience tended to detect lesions earlier in the search than did readers with less experience, but those with less experience tended to spend more time overall searching the images and cover more image area than did those with more experience. CONCLUSION Gaze duration is a useful predictor of missed lesions in mammography, making gaze duration a potential tool for perceptual feedback. Mammographic search for readers with different degrees of experience can be characterized by gaze durations, scan paths, and detection times.

The Role of Formal Art Training on Perception and Aesthetic Judgment of Art Compositions

Does formal art training educate the eye by enabling the viewer to carry out the type of in-depth analysis of the composition elements called for in Berlyne’s theory? Do differences in visual exploration contribute to aesthetic judgment? To answer these questions, the present study compares visual exploration patterns of art-trained and untrained viewers who judged compositions that differed in balance through manipulation of symmetrical organization.

Bone marrow edema pattern in advanced hip osteoarthritis: quantitative assessment with magnetic resonance imaging and correlation with clinical examination, radiographic findings, and histopathology.

ObjectiveTo correlate the amount of bone marrow edema (BME) calculated by magnetic resonance imaging(MRI) with clinical findings, histopathology, and radiographic findings, in patients with advanced hip osteoarthritis(OA).Materials and methodsThe study was approved by The Institutional Human Subject Protection Committee. Coronal MRI of hips was acquired in 19 patients who underwent hip replacement. A spin echo (SE) sequence with four echoes and separate fast spin echo (FSE) proton density (PD)-weighted SE sequences of fat (F) and water (W) were acquired with water and fat suppression, respectively. T2 and water:fat ratio calculations were made for the outlined regions of interest. The calculated MRI values were correlated with the clinical, radiographic, and histopathologic findings.ResultsAnalyses of variance were done on the MRI data for W/(W + F) and for T2 values (total and focal values) for the symptomatic and contralateral hips. The values were significantly higher in the study group. Statistically significant correlations were found between pain and total W/(W + F), pain and focal T2 values, and the number of microfractures and calculated BME for the focal W/(W + F) in the proximal femora. Statistically significant correlations were found between the radiographic findings and MRI values for total W/(W + F), focal W/(W + F) and focal T2 and among the radiographic findings, pain, and hip movement. On histopathology, only a small amount of BME was seen in eight proximal femora.ConclusionThe amount of BME in the OA hip, as measured by MRI, correlates with the severity of pain, radiographic findings, and number of microfractures.

Current perspectives in medical image perception.

Medical images constitute a core portion of the information a physician utilizes to render diagnostic and treatment decisions. At a fundamental level, this diagnostic process involves two basic processes: visually inspecting the image (visual perception) and rendering an interpretation (cognition). The likelihood of error in the interpretation of medical images is, unfortunately, not negligible. Errors do occur, and patients’ lives are impacted, underscoring our need to understand how physicians interact with the information in an image during the interpretation process. With improved understanding, we can develop ways to further improve decision making and, thus, to improve patient care. The science of medical image perception is dedicated to understanding and improving the clinical interpretation process.

The taxonomy of telemedicine.

The purpose of this article is to present a taxonomy for telemedicine. The field has markedly grown, with an increasing number of applications, a variety of technologies, and newly introduced terminology. A taxonomy would serve to bring conceptual clarity to this burgeoning set of alternatives to in-person healthcare delivery. The article starts with a brief discussion of the importance of taxonomy as an information management strategy to improve knowledge sharing, facilitate research and policy initiatives, and provide some guidance for the orderly development of telemedicine. We provide a conceptual context for the proliferation of related concepts, such as telehealth, e-health, and m-health, as well as a classification of the content of these concepts. Our main concern is to develop an explicit taxonomy of telemedicine and to demonstrate how it can be used to provide definitive information about the true effects of telemedicine in terms of cost, quality, and access. Taxonomy development and refinement is an iterative process. If this initial attempt at classification proves useful, subject matter experts could enhance the development and proliferation of telemedicine by testing, revising, and verifying this taxonomy.

Searching for Lung Nodules: Visual Dwell Indicates Locations of False-positive and False-negative Decisions

Eye position recordings made while radiologists searched chest images for lung nodules showed that regions falsely reported positive or suspicious received prolonged visual attention. Correlation of regional fixation dwell time with independent ratings of image features indicated that more than 90% of false-positive decisions were caused by some perturbation in the image that aroused the suspicion of the viewer. The remainder apparently arose from within the viewer. Most missed nodules (false-negative reports) also received prolonged visual attention, implying an active decision not to perceive a nodule. The data are interpreted to show that roughly one task-related decision is made during each second of scanning a radiograph. This departs from the central assumption of the traditional signal-detection model based upon one decision per image.

The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Long Radiology Workdays Reduce Detection and Accommodation Accuracy

PURPOSE The aim of this study was to measure the diagnostic accuracy of fracture detection, visual accommodation, reading time, and subjective ratings of fatigue and visual strain before and after a day of clinical reading. METHODS Forty attending radiologists and radiology residents viewed 60 deidentified, HIPAA-compliant bone examinations, half with fractures, once before any clinical reading (early) and once after a day of clinical reading (late). Reading time was recorded. Visual accommodation (the ability to maintain focus) was measured before and after each reading session. Subjective ratings of symptoms of fatigue and oculomotor strain were collected. The study was approved by local institutional review boards. RESULTS Diagnostic accuracy was reduced significantly after a day of clinical reading, with average areas under the receiver operating characteristic curves of 0.885 for early reading and 0.852 for late reading (P < .05). After a day of image interpretation, visual accommodation was no more variable, though error in visual accommodation was greater (P < .01), and subjective ratings of fatigue were higher. CONCLUSIONS After a day of clinical reading, radiologists have reduced ability to focus, increased symptoms of fatigue and oculomotor strain, and reduced ability to detect fractures. Radiologists need to be aware of the effects of fatigue on diagnostic accuracy and take steps to mitigate these effects.