Portable telepathology: methods and tools

Telepathology is becoming easier to implement in most pathology departments. In fact e-mail image transmit can be done from almost any pathologist as a simplistic telepathology system. We tried to develop a way to improve capabilities of communication among pathologists with the idea that the system should be affordable for everybody. We took the premise that any pathology department would have microscopes and computers with Internet connection, and selected a few elements to convert them into a telepathology station. Needs were reduced to a camera to collect images, a universal microscope adapter for the camera, a device to connect the camera to the computer, and a software for the remote image transmit. We found out a microscope adapter (MaxView Plus) that allowed us connect almost any domestic digital camera to any microscope. The video out signal from the camera was sent to the computer through an Aver Media USB connector. At last, we selected a group of portable applications that were assembled into a USB memory device. Portable applications are computer programs that can be carried generally on USB flash drives, but also in any other portable device, and used on any (Windows) computer without installation. Besides, when unplugging the device, none of personal data is left behind. We selected open-source applications, and based the pathology image transmission to VLC Media Player due to its functionality as streaming server, portability and ease of use and configuration. Audio transmission was usually done through normal phone lines. We also employed alternative videoconferencing software, SightSpeed for bi-directional image transmission from microscopes, and conventional cameras allowing visual communication and also image transmit from gross pathology specimens. All these elements allowed us to install and use a telepathology system in a few minutes, fully prepared for real time image broadcast.     

Pathology background of targeted therapy; quality control in pathology

The administration of targeted therapy of gastric carcinoma is a very important recent improvement of its treatment and prognosis. The basis of the successful treatment is the excellent quality of pathology, now including HER2 testing: the use of validated methods and strict criteria. This is especially important if we consider that many gastric cancers are diagnosed in small biopsy material, in which HER2 testing is challenging. This requires standardized, validated methods and experienced pathologists. Being of diagnostic and predictive significance, high quality of both the technique and the interpretation of the test is mandatory. In order to achieve general high quality in this field, technical and interpretation external quality control of HER2 testing is necessary. Hungarian pathologists with the help of Roche Hungary Ltd. completed an external quality control round which showed that most of the participating laboratories are able. Kulka J, Szirtes I, Szász AM, Kupcsulik P, Kenessey I, Lotz G, Tímár J. Pathology background of targeted therapy; quality control in pathology.     

Digital image analysis in pathology: benefits and obligation

Pathology has recently entered the era of personalized medicine. This brings new expectations for the accuracy and precision of tissue-based diagnosis, in particular, when quantification of histologic features and biomarker expression is required. While for many years traditional pathologic diagnosis has been regarded as ground truth, this concept is no longer sufficient in contemporary tissue-based biomarker research and clinical use. Another major change in pathology is brought by the advancement of virtual microscopy technology enabling digitization of microscopy slides and presenting new opportunities for digital image analysis. Computerized vision provides an immediate benefit of increased capacity (automation) and precision (reproducibility), but not necessarily the accuracy of the analysis. To achieve the benefit of accuracy, pathologists will have to assume an obligation of validation and quality assurance of the image analysis algorithms. Reference values are needed to measure and control the accuracy. Although pathologists' consensus values are commonly used to validate these tools, we argue that the ground truth can be best achieved by stereology methods, estimating the same variable as an algorithm is intended to do. Proper adoption of the new technology will require a new quantitative mentality in pathology. In order to see a complete and sharp picture of a disease, pathologists will need to learn to use both their analogue and digital eyes.     

Introducing the Internet.

The benefits to medical practitioners of using the Internet are growing rapidly as the Internet becomes easier to use and ever more biomedical resources become available on line. The Internet is the largest computer network in the world; it is also a virtual community, larger than many nation states, with its own rules of behaviour or "netiquette." There are several types of Internet connection and various ways of acquiring a connection. Once connected, you can obtain, free of charge, programs that allow easy use of the Internet''s resources and help on how to use these resources; you can access many of these resources through the hypertext references in the on line version of this series (go to http:@www.bmj.com/bmj/ to reach the electronic version). You can then explore the various methods for accessing, manipulating, or disseminating data on the Internet, such as electronic mail, telnet, file transfer protocol, and the world wide web. Results from a search of the world wide web for information on the rare condition of Recklinghausen''s neurofibromatosis illustrate the breadth of medical information available on the Internet.     

Pathogenicity and virulence

Invertebrate pathologists have multiple definitions for the terms pathogenicity and virulence, and these definitions vary across disciplines that focus on host-pathogen interactions. We surveyed various literatures, including plant pathology, invertebrate pathology, evolutionary biology, and medicine, and found most define pathogenicity as the broader term, which incorporates virulence. Virulence is seen as the severity of disease manifestation that can only be measured in infected individuals. These definitions readily apply to both lethal and non-lethal diseases. Invertebrate pathologists commonly use dose-response bioassays to estimate LD(50) or LC(50) (dose or concentration needed to kill 50% of hosts exposed). These bioassays measure pathogenicity if the bioassay includes a transmission component, and measure virulence if the bioassay is measured in infected individuals only. Another common bioassay estimate is LT(50) (median time to death of infected hosts), which is a measure of virulence as long as survivors are not included in its calculation.     

Electronic mail.

Electronic mail (email) has many advantages over other forms of communication: it is easy to use, free of charge, fast, and delivers information in a digital format. As a text only medium, email is usually less formal in style than conventional correspondence and may contain acronyms and other features, such as smileys, that are peculiar to the Internet. Email client programs that run on your own microcomputer render email powerful and easy to use. With suitable encoding methods, email can be used to send any kind of computer file, including pictures, sounds, programs, and movies. Numerous biomedical electronic mailing lists and other Internet services are accessible by email.     

Quantitative evaluation of immunohistochemical staining in gastrointestinal stromal tumors

OBJECTIVE: To evaluate the differences among pathologists' interpretations in gastrointestinal stromal tumors (GISTs) and to demonstrate the usefulness of quantitative pathology in the assessment of immunohistochemical staining. STUDY DESIGN: Twenty GISTs were separately evaluated by 4 pathologists by the visual estimation method using a 6-antibody panel. Each case was then quantitatively measured with a computer-assisted image analysis system by 2 pathologists. Cohen's kappa test was performed for statistical analysis. RESULTS: All GISTs showed some degree of expression of CD 117, CD34, SMA and Ki-67. No case was immunoreactive for desmin or S-100 protein. There were remarkable differences in the pathologists' visual estimations. Moreover, the discrepancies between visual and quantitative methods were noteworthy. The differences in interpretations showed the greatest variability for Ki-67, which is known to be related to poor prognosis. CONCLUSION: Quantitative pathology in assessment of immunohistochemical staining of GISTs may improve the consistency in the interpretation of staining results and provide some degree of reproducibility.     

Basic aspects of and recent developments in telepathology in Europe, with specific emphasis on quality assurance

Telepathology is the diagnostic work of a pathologist from a distance and includes all specific fields of diagnostic pathology, such as frozen section services, expert consultation, cytometric and histometric measurement, and continuous education. For about 15 years experience has been collected at several universities in the United States and Europe based upon analog telephone lines (9.2 kbaud), digitized lines (ISDN, 64 kbaud), broad band connections (1.5 Mbaud) and the World Wide Web (28 kbaud). Potential use can be expected in the application of telepresentation, remote slide preparation, remote central diagnostics and telediscussion. The transfer of still images is well developed; that of live images is used in only a few institutions for frozen section services. The image quality and spatial resolution as well as the transfer speed are sufficient for expert consultations, morphometric measurements, quality assurance and education. All applications focus on discontinuous work flow. Although the European Community focuses on user needs and standardization aspects of telepathology by sponsoring a widespread telepathology project (Europath), implementation of telepathology into routine application in the continuous work flow has still to be developed. The technical equipment has still to be adjusted to the labor flow charts in routine pathologic diagnostic procedures. Telepathology seems to be the appropriate technique to offer both improvement in diagnostic quality and inclusion of the "control institution" into diagnostic responsibility.     

Digital pathology in personalized cancer therapy

The development of small molecule inhibitors of growth factor receptors, and the discovery of somatic mutations of the tyrosine kinase domain, have resulted in new paradigms for cancer therapy. Digital microscopy is an important tool for surgical pathologists. The achievements in the digital pathology field have modified the workflow of pathomorphology labs, enhanced the pathologist's role in diagnostics, and increased their contribution to personalized targeted medicine. Digital image analysis is now available in a variety of platforms to improve quantification performance of diagnostic pathology. We here describe the state of digital microscopy as it applies to the field of quantitative immunohistochemistry of biomarkers related to the clinical personalized targeted therapy of breast cancer, non-small lung cancer and colorectal cancer: HER-2, EGFR, KRAS and BRAF genes. The information is derived from the experience of the authors and a review of the literature.     

Use of monoclonal antibodies in identification and characterization of fish viruses

Monoclonal antibodies (MAbs) for fish viruses have been used increasingly in fish health management programs and as tools in research. The initial and most widespread use has been in the development of improved diagnostic and virus identification assays. MAbs with broad reactivity that provide standardized reagents for use in general screening assays for particular groups of fish viruses have been developed, whereas MAbs with more restricted specificities permit the rapid serotyping of fish viruses and, in some cases, the identification of specific virus strains. The large number and variety of MAbs now available for some fish viruses, such as the aquatic birnaviruses and rhabdoviruses, present an ideal opportunity to select appropriate MAbs to construct standardized virus identification assays for use by all fish pathologists worldwide. Furthermore, these MAbs have been used to identify specific epitopes that stimulate a protective immune response to many fish viruses, and to investigate the mechanisms of antibody-mediated neutralization of fish viruses. They also have been used to study the epidemiology of specific viruses as well as antigenic variation and the mechanisms by which new strains arise. Such information is important for the development of reliable diagnostic assays for short-term control methods as well as the development of effective vaccines for long-term control of virus diseases in fish. This article presents a brief overview of MAb production and a review of some current applications of MAbs in the identification and characterization of viruses of fish.     

Education and training for cytopathologists. Its role in quality assurance

The role of education and training for cytopathologists in assuring quality in cytology laboratories is discussed, with particular attention given to (1) the problems in the diagnosis of Papanicolaou smears and (2) the contributions of the American Society of Cytology to cytology education. While many people contribute to the success or failure of gynecologic screening programs, poorly trained pathologists can be an especially weak link in the chain given their position in the diagnostic process. Well-formulated residency programs and the use of other educational resources can produce higher-caliber cytopathologists. The problems in Papanicolaou smear screening need to be defined, discussed and resolved by well-trained cytopathologists in conjunction with the clinicians and cytotechnologists involved.     

Coding for pathology tests - strengths and weaknesses

Laboratory professionals will increasingly find themselves called upon to assist with the coding of pathology test requests and reported results in the era of the e-Health Record (EHR). EHR users from outside pathology, including patients and clinicians, will expect seamless integration of pathology services, and question variations in test nomenclature, units, reference intervals, and interpretive comments. Scientists and pathologists will need to be ready to work with colleagues outside their traditional scientific disciplines, along with IT and terminology experts, to resolve illogical historical variations, highlight differences that might endanger patient safety, and help lay the foundations for evolving e-health systems that enhance healthcare without eroding the interpretive value of pathology reports from different laboratories. An overview of medical terminologies and Australasian eHealth harmonisation programs is also provided.     

The value of lymph node imprint cytodiagnosis: an assessment of interobserver agreement and diagnostic accuracy

The value of lymph node imprint cytodiagnosis: an assessment of interobserver agreement and diagnostic accuracy
The aim of this study was to assess the reliability of cytodiagnosis of lymph node imprints without fixed tissue sections. One hundred randomly selected archival cases were used in the study. These air‐dried May–Grünwald–Giemsa imprint slides were assessed independently and blind by three pathologists. Cases were assigned to one of four diagnostic categories: reactive changes, non‐Hodgkin's lymphoma (NHL), Hodgkin's disease (HD) and secondary malignancy. Each broad diagnosis was compared with the 'correct' reviewed histological diagnosis to calculate interobserver agreement and diagnostic accuracy. The overall κ score (+0.59) was indicative of moderate agreement. The mean pathologist diagnostic accuracy was 78%, with complete agreement with the histological diagnosis in 61% of cases. The main diagnostic difficulties were in the distinction between reactive changes and NHL and distinguishing NHL from HD. Further diagnostic classification, e.g. typing of lymphomas and subclassification of Hodgkin's disease, was not found to be reliable using the imprints alone. With these limitations in mind, pathologists should be able to use lymph node imprints for cytodiagnosis in selected cases. The study also emphasized the utility of imprints as a corollary to the histology and as a tool for cytology training and continuing education.     

Electricity Intensity of Internet Data Transmission: Untangling the Estimates

In order to understand the electricity use of Internet services, it is important to have accurate estimates for the average electricity intensity of transmitting data through the Internet (measured as kilowatt‐hours per gigabyte [kWh/GB]). This study identifies representative estimates for the average electricity intensity of fixed‐line Internet transmission networks over time and suggests criteria for making accurate estimates in the future. Differences in system boundary, assumptions used, and year to which the data apply significantly affect such estimates. Surprisingly, methodology used is not a major source of error, as has been suggested in the past. This article derives criteria to identify accurate estimates over time and provides a new estimate of 0.06 kWh/GB for 2015. By retroactively applying our criteria to existing studies, we were able to determine that the electricity intensity of data transmission (core and fixed‐line access networks) has decreased by half approximately every 2 years since 2000 (for developed countries), a rate of change comparable to that found in the efficiency of computing more generally.     

Using MATLAB software with Tomcat server and Java platform for remote image analysis in pathology

Background

The Matlab software is a one of the most advanced development tool for application in engineering practice. From our point of view the most important is the image processing toolbox, offering many built-in functions, including mathematical morphology, and implementation of a many artificial neural networks as AI. It is very popular platform for creation of the specialized program for image analysis, also in pathology. Based on the latest version of Matlab Builder Java toolbox, it is possible to create the software, serving as a remote system for image analysis in pathology via internet communication. The internet platform can be realized based on Java Servlet Pages with Tomcat server as servlet container.

Methods

In presented software implementation we propose remote image analysis realized by Matlab algorithms. These algorithms can be compiled to executable jar file with the help of Matlab Builder Java toolbox. The Matlab function must be declared with the set of input data, output structure with numerical results and Matlab web figure. Any function prepared in that manner can be used as a Java function in Java Servlet Pages (JSP). The graphical user interface providing the input data and displaying the results (also in graphical form) must be implemented in JSP. Additionally the data storage to database can be implemented within algorithm written in Matlab with the help of Matlab Database Toolbox directly with the image processing. The complete JSP page can be run by Tomcat server.

Results

The proposed tool for remote image analysis was tested on the Computerized Analysis of Medical Images (CAMI) software developed by author. The user provides image and case information (diagnosis, staining, image parameter etc.). When analysis is initialized, input data with image are sent to servlet on Tomcat. When analysis is done, client obtains the graphical results as an image with marked recognized cells and also the quantitative output. Additionally, the results are stored in a server database. The internet platform was tested on PC Intel Core2 Duo T9600 2.8GHz 4GB RAM server with 768x576 pixel size, 1.28Mb tiff format images reffering to meningioma tumour (x400, Ki-67/MIB-1). The time consumption was as following: at analysis by CAMI, locally on a server – 3.5 seconds, at remote analysis – 26 seconds, from which 22 seconds were used for data transfer via internet connection. At jpg format image (102 Kb) the consumption time was reduced to 14 seconds.

Conclusions

The results have confirmed that designed remote platform can be useful for pathology image analysis. The time consumption is depended mainly on the image size and speed of the internet connections. The presented implementation can be used for many types of analysis at different staining, tissue, morphometry approaches, etc. The significant problem is the implementation of the JSP page in the multithread form, that can be used parallelly by many users. The presented platform for image analysis in pathology can be especially useful for small laboratory without its own image analysis system.

     

Internet-based medical education

The Internet is revolutionizing medical education and medical practice by enabling teachers and students to utilize and integrate many forms of data in ways that cannot be done via classic textbooks. In cardiovascular medicine, dynamic images are essential for understanding cardiac function, coronary anatomy, and myocardial perfusion, as well as for learning cardiovascular pathophysiology and the typical and atypical presentations of disease states. Cardiosource, an educational Web site developed by the American College of Cardiology, illustrates the ways in which the Internet is being used to improve medical education and practice.     

Online teaching of inflammatory skin pathology by a French-speaking International University Network

Introduction

Developments in technology, web-based teaching and whole slide imaging have broadened the teaching horizon in anatomic pathology. Creating online learning material including many types of media such as radiologic images, whole slides, videos, clinical and macroscopic photographs, is now accessible to most universities. Unfortunately, a major limiting factor to maintain and update the learning material is the amount of resources needed. In this perspective, a French-national university network was initiated in 2011 to build joint online teaching modules consisting of clinical cases and tests. The network has since expanded internationally to Québec, Switzerland and Ivory Coast.

Method

One of the first steps of the project was to build a learning module on inflammatory skin pathology for interns and residents in pathology and dermatology. A pathology resident from Québec spent 6 weeks in France and Switzerland to develop the contents and build the module on an e-learning Moodle platform under the supervision of two dermatopathologists. The learning module contains text, interactive clinical cases, tests with feedback, virtual slides, images and clinical photographs. For that module, the virtual slides are decentralized in 2 universities (Bordeaux and Paris 7). Each university is responsible of its own slide scanning, image storage and online display with virtual slide viewers.

Results

The module on inflammatory skin pathology includes more than 50 web pages with French original content, tests and clinical cases, links to over 45 virtual images and more than 50 microscopic and clinical photographs. The whole learning module is being revised by four dermatopathologists and two senior pathologists. It will be accessible to interns and residents in the spring of 2014. The experience and knowledge gained from that work will be transferred to the next international resident whose work will be aimed at creating lung and breast pathology learning modules.

Conclusion

The challenges of sustaining a project of this scope are numerous. The technical aspect of whole-slide imaging and storage needs to be developed by each university or group. The content needs to be regularly updated and its accuracy reviewed by experts in each individual domain. The learning modules also need to be promoted within the academic community to ensure maximal benefit for trainees. A collateral benefit of the project was the establishment of international partnerships between French-speaking universities and pathologists with the common goal of promoting pathology education through the use of multi-media technology including whole slide imaging.

     

Elsie 4: quantitative computer analysis of sets of two-dimensional gel electrophoretograms

We have developed and refined a system for quantitative computer analysis of two-dimensional polyacrylamide gel electrophoretograms. The system, named Elsie 4, is based on one described by Vo et al. (Anal. Biochem. 112, 258 (1981]. It is highly automated. Elsie 4 can find, and measure the intensity of, almost any spot resolvable on two-dimensional gels, including spots visible only as shoulders off larger spots and spots so close together that there is no "valley" between them. It can automatically match the spot patterns of different gels, potentially without the need for a user to provide landmark matches. The matches between paired gels let us follow the synthesis of any spot through a set of gels. Information about a group of matched spots can be obtained by referring to any spot in the group. There is generally no need for a standard or reference gel. Data for two experiments can be combined and compared by matching any gel in one experiment with any gel in the other. There are ways to automatically find possible mismatches in sets of gels. Scans and the results of the analysis can be shown on an image displayer. The programs use function libraries; this helps ensure consistency and increase portability. The programs and functions can be linked together in many ways; this lets users build custom programs for analysis of specific experiments.     

Possible pathogenic pathways in the adverse clinical events seen following ivermectin administration to onchocerciasis patients.

BACKGROUND: Reactions are commonly associated with the chemotherapy of onchocerciasis. However unmanageable reactions are uncommon when ivermectin (Mectizan(R)) is used for the treatment of this infection, and this drug has proved to be a great improvement over previously used agents. Serious adverse events (SAE) nevertheless have occurred, and there is considerable concern about the negative effect such events may have on mass drug administration programs.This paper reviews the basic pathogenic mechanisms that can be involved in the destruction of microfilaria by chemotherapeutic agents. A central challenge to filarial chemotherapy is the need to remove parasites from biologically sensitive tissues, a more difficult medical challenge than eliminating nematodes from the gastrointestinal tract.Explanations for the etiology of the serious adverse reactions occurring with ivermectin treatment in specific geographic areas where there is coincident heavy Loa loa infections are hampered by a lack of specific pathological case material. Ways to investigate these possibilities are reviewed. Possible pathogenic mechanisms include embolic vascular pathology accompanied by local inflammation, blood brain barrier mdr1 abnormalities, and genetic predisposition to excessive inflammatory responses. CONCLUSION: It is important to keep ivermectin, and all its associated adverse clinical events, in perspective with the many other chemotherapeutic agents in general use - many of which produce serious adverse events even more frequently than does ivermectin. Currently available evidence indicates that the pathogenesis of the Loa-associated adverse reactions are probably related to inflammatory responses to microfilariae in specific tissues. However, the possibility of genetic predispositions to pathology should also be considered.