Acceptance of telepathology in daily practice.

The availability of pathology services differs greatly in our environment. Although pathology would be especially suitable for being practised at a distance by transporting digital image information, the spread of telepathology into everyday work still is relatively slow. The article describes the situation of diffusion of this innovative technology by reviewing the literature and discussing this in context to data based on questionnaires dealing with the acceptance of telepathology. The current situation of telepathology can be discussed by five items for innovation spead: (1) communication and influence; (2) economic costs and benefits; (3) knowledge barriers and learning; (4) feasibility of techniques offered for the demands of the users; (5) clarification of the legal status and other factors concerning international collaboration. All these head lines do not represent realistic obstacles for the more widespread use of telepathology. The real drawbacks may therefore be found behind certain professional habits of pathologists. The most important causes may be that (a) telediagnosis is not as easy as it may seem at the first glance; (b) telepathology is seen as a potential highway to a world-wide competition of pathology service providers. As soon as these mostly unjustified prejudices are corrected and telepathology is percepted as additional technique in pathology, it will become a diagnostic tool as common and as useful as the telephone.     

How could static telepathology improve diagnosis in neuropathology?

The present paper reports our experience with, and our opinion of static telepathology as applied to neuropathology by means of the PHAROS acquisition system and conventional telephone data transmission (modem). The classical procedure of expert consultation based on surface mailing of histological slides is routinely performed, especially in highly specialized fields of pathology. Telepathology is an easy means of sharing scientific expertise at international level and could thus improve diagnosis particularly in neuropathology, where certain tumor types are very rare and complex to diagnose. Dynamic telepathology allows the referring pathologist to capture by himself images supporting their diagnosis. Using static telepathology the pathologist could be limited in diagnosis by problems in fields selection. We devoted a whole year to collecting all the technical parameters characterizing the use of digitized neuropathological data files in order to investigate the feasibility of telepathology and the extent to which its use could improve diagnoses. Our results on a series of 38 histological brain examinations illustrate how we successfully established an international connection between two departments of pathology in Belgium and the USA. The referring pathologists gave diagnoses in 35 cases and deferred only 3. Despite a time-consuming procedure for the telepathology session of a few cases, this tool provides easy access to expert diagnosis and real-time discussion, both of which are of considerable interest and offer significant improvements in neuropathology.     

Biologie et politique IV. — Questions d'éthique

Within the framework of the increasing development of techniques and technology, Humankind is often considered and used as an instrument. Because power from the industry can generate bad consequences that are unforeseeable and thus out of a comprehensive control, new thoughts on Mankind and its values are needed. The moral code gives the practical distinction between good and evil. Ethics calls to a reflection from free, reasonable and responsible beings. Numerous groups of thoughts working for a progressive emergence of universally admitted ethic rules that should allow the offer of an international right of ‘Human rights’ are now available at different levels, i.e. professional, national, international. From the biomedical ethic, it appears that Human beings, considered as biological entities, have the right to live, that the embryo must not be used as an usual research material and that the diagnostic of embryos before implantation must be exceptional. Human being has a right to dignity. This means that one must not be submitted to degrading treatments (torture, slavery, …), must have access to health care, must not constitute an experimental object, the germinal cells must not be manipulated and neither his body or its constituting elements must ever be commercialised or patented. Corpses need respect and any attack to their integrity (in order to extract profits for public health, science, justice…) must be justified. A person, defined here as a self-awa-reness constructed in function of other persons, must be free (i.e. his consent is absolutely needed for a diagnostic or experimental treatment) and has economical, social and cultural rights. French laws do not permit a person to choose his death The international law progressively refines a definition of crime against humanity (ethnic extinction, torture, rape…). In the ethics for environment, the respect of men towards animals considered as individuals and species in the framework of the conservation of the nature and genetics resources, is taken into account rather than the rights of animals per se. Finally, an arsenal of agreements, directives and legislation at local, national and international levels attempts to harmonise the practices of the technoscience with the concept of long lasting development, in order to maintain the higher-order balances within ecosystems. Mankind felt itself responsible of the environment for the future generations. Nevertheless, any regulation in the matter of ethic remains a compromise within contradictory views. The only general rule for every one, remains not to harm others, and to give oneself to others. This is, for long time, the traditional basis of religious preachments, although its success remains relatively controversial.     

Remote monitoring and follow-up of cardiovascular implantable electronic devices in the Netherlands : An expert consensus report of the Netherlands Society of Cardiology

Remote monitoring of cardiac implanted electronic devices (CIED: pacemaker, cardiac resynchronisation therapy device and implantable cardioverter defibrillator) has been developed for technical control and follow-up using transtelephonic data transmission. In addition, automatic or patient-triggered alerts are sent to the cardiologist or allied professional who can respond if necessary with various interventions. The advantage of remote monitoring appears obvious in impending CIED failures and suspected symptoms but is less likely in routine follow-up of CIED. For this follow-up the indications, quality of care, cost-effectiveneness and patient satisfaction have to be determined before remote CIED monitoring can be applied in daily practice. Nevertheless remote CIED monitoring is expanding rapidly in the Netherlands without professional agreements about methodology, responsibilities of all the parties involved and that of the device patient, and reimbursement. The purpose of this consensus document on remote CIED monitoring and follow-up is to lay the base for a nationwide, uniform implementation in the Netherlands. This report describes the technical communication, current indications, benefits and limitations of remote CIED monitoring and follow-up, the role of the patient and device manufacturer, and costs and reimbursement. The view of cardiology experts and of other disciplines in conjunction with literature was incorporated in a preliminary series of recommendations. In addition, an overview of the questions related to remote CIED monitoring that need to be answered is given. This consensus document can be used for future guidelines for the Dutch profession.     

Participation of Colorado pediatricians and family physicians in the Medicaid program.

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients.     

Biobanks for genomics and genomics for biobanks

Biobanks include biological samples and attached databases. Human biobanks occur in research, technological development and medical activities. Population genomics is highly dependent on the availability of large biobanks. Ethical issues must be considered: protecting the rights of those people whose samples or data are in biobanks (information, autonomy, confidentiality, protection of private life), assuring the non-commercial use of human body elements and the optimal use of samples and data. They balance other issues, such as protecting the rights of researchers and companies, allowing long-term use of biobanks while detailed information on future uses is not available. At the level of populations, the traditional form of informed consent is challenged. Other dimensions relate to the rights of a group as such, in addition to individual rights. Conditions of return of results and/or benefit to a population need to be defined. With 'large-scale biobanking' a marked trend in genomics, new societal dimensions appear, regarding communication, debate, regulation, societal control and valorization of such large biobanks. Exploring how genomics can help health sector biobanks to become more rationally constituted and exploited is an interesting perspective. For example, evaluating how genomic approaches can help in optimizing haematopoietic stem cell donor registries using new markers and high-throughput techniques to increase immunogenetic variability in such registries is a challenge currently being addressed. Ethical issues in such contexts are important, as not only individual decisions or projects are concerned, but also national policies in the international arena and organization of democratic debate about science, medicine and society.     

Legal instruments in private land conservation: the nature and role of conservation contracts and conservation covenants

Management of private land for ecological outcomes has emerged as an important facet of biodiversity management and ecological restoration in Australia. Common law conservation contracts and conservation covenants are important tools within this framework of private land conservation. They can provide legal protections to biodiversity and natural assets on private land, as well as legal frameworks, in the form of obligations, to restoration programs. They can provide distinct qualities of binding obligation: fixed term or enduring. Conservation contracts and covenants need to be recognized as possessing both transactional and relational qualities, and these qualities should be considered and reflected in the design of agreements and in practices of conservation management and agreement‐making. Two design questions are considered in this article. Conservation agreements need to contend with dynamism in ecological and social realities and this may be accommodated in mechanisms for adjustment of obligations between or within agreements. Dispute management is a second field of practice and drafting requiring attention. Constructing disputes provisions that are adapted and appropriate to long‐term conservation actions and restoration initiatives is reflective of good faith principles and can include scope for graduated, independent, corrective, and fair arrangements, informed as necessary by expert input.     

Fatal collision? Are wireless headsets a risk in treating patients?

Wireless-enabled headsets that connect to the internet can provide remote transcribing of patient examination notes. Audio and video can be captured and transmitted by wireless signals sent from the computer screen in the frame of the glasses. But using wireless glass-type devices can expose the user to a specific absorption rates (SAR) of 1.11–1.46 W/kg of radiofrequency radiation. That RF intensity is as high as or higher than RF emissions of some cell phones. Prolonged use of cell phones used ipsilaterally at the head has been associated with statistically significant increased risk of glioma and acoustic neuroma. Using wireless glasses for extended periods to teach, to perform surgery, or conduct patient exams will expose the medical professional to similar RF exposures which may impair brain performance, cognition and judgment, concentration and attention and increase the risk for brain tumors. The quality of medical care may be compromised by extended use of wireless-embedded devices in health care settings. Both medical professionals and their patients should know the risks of such devices and have a choice about allowing their use during patient exams. Transmission of sensitive patient data over wireless networks may increase the risk of hacking and security breaches leading to losses of private patient medical and financial data that are strictly protected under HIPPA health information privacy laws.     

Recent developments and present status of telepathology.

Telepathology which is the diagnostic work of a pathologist at a distance has been developed to routine application within the last ten years. It can be classified in relation to application, technical solutions, or performance conditions. Diagnostic pathology performance distinguishes primary diagnosis (for example, frozen section statement) from secondary diagnosis (for example, expert consultation) and quality assurance (diagnostic accuracy, continuous education and training). Applications comprise (a) frozen section service; (b) expert consultations; (c) remote control measurements; and (d) education and training. The technical solutions distinguish active (remote control, live imaging) systems from passive (conventional microscope handling, static imaging), and the performance systems with interactive (on-line, live imaging) use from those with passive (offline, static imaging) practice. Intra-operative frozen section service is mainly performed with remote control systems; whereas expert consultations and education/training are commonly based upon Internet connections with static imaging in an off-line mode. The image quality, transfer rates, and screen resolution of active and passive telepathology systems are sufficient for an additional or primary judgment of histological slides and cytological smears. From the technical point of view, remote control telepathology requires a fast transfer and at least near on-line judgement of images, i.e., image acquisition, transfer and presentation can be considered one performance function. Thus, image size, line transfer rate and screen resolution define the practicability of the system. In expert consultation, the pixel resolution of images and natural color presentation are the main factors for diagnostic support, whereas the line transfer rate is of minor importance. These conditions define the technical compartments, especially size and resolution of camera and screen. The performance of commercially available systems has reached a high quality standard. Pathologists can be trained in a short time and use the systems in a routine manner. Several telepathology systems have been implemented in large Institutes of Pathology which serve for frozen section diagnosis in small hospitals located in the local area. In contrast, expert consultation is mainly performed with international connections. There is a remarkable increase of expert consultations by telepathology according to the experiences of the Armed Forces Institute of Pathology or the Department of Pathology, Thoraxklinik, Heidelberg. In expansion of these experiences, a "globalization" of telepathology can be expected. Telepathology can be used to shrink the period necessary for final diagnosis by request for diagnostic assistance to colleagues working in appropriate related time zones. Telepathology is, therefore, not a substitute of conventional diagnostic procedures but a real improvement in the world of pathology.     

The importance of the selection of the audiences and the organization of media events within public awareness strategies for tissue banks

The main purpose of the International Atomic Energy Agency (IAEA) Public Awareness Strategies for Tissue Banks is to provide guidance on organizing and running awareness campaigns, in order to consolidate tissue banking activities. Within the IAEA Public Awareness Strategies for Tissue Banks, there are two important topics, which need to be singled out due to their importance for a successful public and professional awareness campaign. These are the selection of the audiences and the organization of media events within a Communication Strategy. The experience in the field of tissue banking in several countries has shown that interaction between the public, the professional health care staff, the media and the tissue bank personnel is essential if the activities of the banks are to be successful. It must be emphasized however, that any public and professional awareness strategy will not be successful, unless it is considered as part of an integrated system that is adopted by the concerned Government.     

American Security and Law of the Sea

With the election of President Barack Obama and renewed interest in the Law of the Sea Convention inside the United States, this article pulls from obscurity the key U.S. declarations, understandings, and conditions of ratification to the Treaty, considers their context and meaning for U.S. security interests, and helps to place them into the lexicon of oceans law and policy that informs the greater dialogue of international security and strategy.     

Custom In The Courtroom, Law In The Village: Legal Transformations In Papua New Guinea

After more than twenty-five years on the legal landscape of Papua New Guinea, 'customary law' is ripe for reassessment, particularly as it appears to be an ideal mechanism with which the Papua New Guinean state can meet some of its obligations to a burgeoning body of international law. This article addresses the need to understand customary law in the context of its varying usage across different legal domains in an archetypally pluralistic state. In contrast to older approaches focusing on the problematic interface between an exogenous legal system and indigenous methods of dispute settlement, my concern is with the ways in which these distinct legal forms have fared in each other's company since independence in 1975. Case-studies from a village court and an urban national court demonstrate that village court magistrates and high court judges alike use custom and law as strategic sources of authority. While village courts take custom for granted and therefore must 'discover' law, high courts take law for granted and must 'discover' custom. These processes indicate that, rather than being hybridized as 'customary law', the distinctiveness of custom and law are often maintained in order for one to appear as a resource upon which the other can draw.     

Uncompensated and undercompensated care provided by San Francisco Medical Society physicians.

Practicing physician members of the San Francisco Medical Society were surveyed regarding reimbursement rates for medical care provided to underinsured and uninsured patients. Of 394 respondents, about $51,000 per physician practice was written off as uncompensated care or services not billed for in 1985. An average of 7% of each physician''s patients was estimated to be "no-pay" or charity patients, accounting for $19,000 of this total. Almost $32,000 was reported as being uncompensated care, or that which is billed but not paid. In addition to these amounts, an average of $32,000 was reported as being discounted from the usual fee levels by government insurance programs. Extrapolating these results to the physician membership of the local medical society indicates that physicians in San Francisco may be providing as much as $81 million in uncompensated or charity care annually. These results emphasize that private practitioners are providing a significant amount of medical care at reduced or charity rates, an amount that can be expected to increase given present trends. Substantial changes are needed if the burden of providing medical care to poor and uninsured Americans is not to fall disproportionately on private providers.     

Globalizing biosecurity

A harmonized international regime that enhances biosecurity is needed to reduce the risk of bioterrorism. Like other security regimes, this will entail mutually reinforcing strands, which need to include: enactment of legally binding control of access to dangerous pathogens, transparency for sanctioned biodefense programs, technology transfer and assistance to developing countries to jointly advance biosafety and biosecurity, global awareness of the dual-use dilemma and the potential misuse of science by terrorists, and development of a global ethic of compliance. To work, this effort must be undertaken collectively, utilizing the international and regional institutions that already have a role to play in providing safety and security. Most notably, it must grow in a top-down manner from the Biological Weapons Convention accord, in which States Parties have agreed to ban the development of biological weapons, and in a bottom-up manner from the scientific and health communities, which are engaged in the research and public health efforts that must be protected against misuse-especially involving the World Health Organization.     

Health policy and ethnic diversity in older Americans. Dissonance or harmony?

The rapid growth and diversity of the older population have long-term implications for health care policies in the United States. Current policies designed for a homogeneous population are increasingly obsolete. To ameliorate obstacles that handicap many ethnic minority elders and to provide equal access to adequate and acceptable health care, several factors need to be considered. Enhanced data collection and analytic techniques are needed. The effects of race or ethnicity must be separated from other biologic, environmental, socioeconomic, cultural, and temporal factors on health status and behavior. Health care professionals and organizations serving minority elders must continue to expand their advocacy efforts to articulate the findings and their concerns to policymakers. Policymakers must understand and acknowledge the implications of an increasingly diverse society and determine what will constitute adequate, accessible, and acceptable health care within continuing fiscal constrains. Program planning, implementation, and evaluation methods must be revised to meet future health care needs effectively and efficiently.     

Healthy firms: constraints to growth among private health sector facilities in Ghana and Kenya

Background

Health outcomes in developing countries continue to lag the developed world, and many countries are not on target to meet the Millennium Development Goals. The private health sector provides much of the care in many developing countries (e.g., approximately 50 percent in Sub-Saharan Africa), but private providers are often poorly integrated into the health system. Efforts to improve health systems performance will need to include the private sector and increase its contributions to national health goals. However, the literature on constraints private health care providers face is limited.

Methodology/Principal Findings

We analyze data from a survey of private health facilities in Kenya and Ghana to evaluate growth constraints facing private providers. A significant portion of facilities (Ghana: 62 percent; Kenya: 40 percent) report limited access to finance as the most significant barrier they face; only a small minority of facilities report using formal credit institutions to finance day to day operations (Ghana: 6 percent; Kenya: 11 percent). Other important barriers include corruption, crime, limited demand for goods and services, and poor public infrastructure. Most facilities have paper-based rather than electronic systems for patient records (Ghana: 30 percent; Kenya: 22 percent), accounting (Ghana: 45 percent; Kenya: 27 percent), and inventory control (Ghana: 41 percent; Kenya: 24 percent). A majority of clinics in both countries report undertaking activities to improve provider skills and to monitor the level and quality of care they provide. However, only a minority of pharmacies report undertaking such activities.

Conclusions/Significance

The results suggest that improved access to finance and improving business processes especially among pharmacies would support improved contributions by private health facilities. These strategies might be complementary if providers are more able to take advantage of increased access to finance when they have the business processes in place for operating a successful business and health facility.     

Translation is not enough. Interpreting in a medical setting.

Unique obstacles must be overcome when providing medical care to patients who have an incomplete command of the English language. Serious barriers to effective communication may arise at the exact point where our health care system must succeed or fail. Miscommunication, differences in attitudes about health care, and various other misunderstandings interfere with or frustrate good health care for these patients and their families. Such difficulties are best overcome by the use of a professional interpreter who can ensure good communication between patients and health care professionals. My daily experiences as a professional medical interpreter and translator in Spanish provide insights into the complexities of bilingual and bicultural communication in the hospital setting. Although the examples given relate to Hispanic patients, the lessons learned can be extended to other foreign language patients as well.     

Standard of Care,Professional Obligations,and Distributive Justice

The problem of standard‐of‐care in clinical research concerns the level of care that investigators ought to provide to research subjects in the control arm of their clinical trials. Commentators differ sharply on whether subjects in trials conducted in lower income countries should be provided with the same level of care as subjects in trials conducted in higher income countries. I consider an argument that commentators have employed on both sides of this debate: professional role arguments. These arguments claim to justify a conclusion to the standard‐of‐care problem solely by appeal to the professional obligations that investigators possess. I argue that prominent versions of professional role arguments cannot justify a solution to the problem of standard‐of‐care that is both determinate and reasonable simply by appeal to the professional obligations of investigators. Instead, to do so, one must also (1) determine the level of care or types of treatment that individuals are entitled to as a matter of distributive justice, and (2) identify which agents possess the duties that correspond to these entitlements. The level of care that investigators owe to subjects in the control arm of their clinical trials is thus in part dependent on the level of care that these subjects are entitled to as a matter of distributive justice, and whether it is the investigators who possess the corresponding distributive obligation to provide them with the care that they are entitled to.     

Telepathology: design of a modular system.

Although telepathology systems have been developed for more than a decade, they are still not a widespread tool for routine diagnostic applications. Lacking interoperability, software that is not satisfying user needs as well as high costs have been identified as reasons. In this paper we would like to demonstrate that with a clear separation of the tasks required for a telepathology application, telepathology systems can be built in a modular way, where many modules can be implemented using standard software components. With such a modular design, systems can be easily adapted to changing user needs and new technological developments and it is easier to integrate modular systems into existing environments.     

Shortfall of equipment for neonatal intensive care and the introduction of budget holding contracts.

As adequate allowance must be made for the costs of purchasing, maintaining, and updating equipment during the development of contracts the current standing of neonatal units with regard to available equipment was assessed. Data were collected as part of a one year prospective survey of the 17 perinatal units in the Trent region. Adequacy of provision of equipment for recognised intensive care cost was assessed using the recommendations of the British Paediatric Association and British Association of Perinatal Paediatrics. It was assumed that units without recognised intensive care cost had to be able to equip one cot to a standard of intensive care level 1 in the short term. Equipment more than 5 years old was considered likely to warrant replacement or major maintenance within the next two years. With these guidelines over 600,000 pounds would be required to provide sufficient equipment for all recognised level 1 intensive care cost and to allow units without funded cost to provide this level of care in the short term and to replace existing equipment more than 5 years old for these cost alone. This amount could be reduced by 25% by subdividing intensive care cost into levels 1 and 2, thereby reducing equipment requirements, but this would impair the units'' ability to perform level 1 care at funded provision, which has already been shown to need expansion. Neither figure takes account of equipment requirements for infants requiring special care. In addition, no allowance has been made for purchase or update of ultrasound scanners or blood gas analysers. If the government''s proposed reforms are to be implemented clinicians need to revise guidelines regarding essential equipment, and plans must be made to correct any existing shortfalls so that they do not become inherited financial liabilities for future budget holders.