Telecytology: Is it possible with smartphone images?

TelePi: an affordable telepathology microscope camera system anyone can build and use

Telepathology facilitates histological diagnoses through sharing expertise between pathologists. However, the associated costs are high and frequently prohibitive, especially in low-resource settings, where telepathology would paradoxically be of paramount importance due to a paucity of pathologists.We have constructed a telepathology system (TelePi) with a budget of < €120 using the small, single-board computer Raspberry Pi Zero and its High-Quality Camera Module in conjunction with a standard microscope and open-source software. The system requires no maintenance costs or service contracts, has a small footprint, can be moved and shared across several microscopes, and is independent from other computer operating systems. TelePi uses a responsive and high-resolution web-based live stream which allows remote consultation between two or more locations. TelePi can serve as a telepathology system for remote diagnostics of frozen sections. Additionally, it can be used as a standard microscope camera for teaching of medical students and for basic research. The quality of the TelePi system compared favorable to a commercially available telepathology system that exceed its cost by more than 125-fold. Additionally, still images are of publication quality equal to that of a whole slide scanner that costs 800 times more.In summary, TelePi is an affordable, versatile, and inexpensive camera system that potentially enables telepathology in low-resource settings without sacrificing image quality.

The use of telecytology for the evaluation of thyroid nodules fine-needle aspiration biopsy specimens: a systematic review

PURPOSE

Fine needle aspiration biopsy (FNAB) is currently the gold standard for diagnosis and treatment of thyroid nodules, but the growing need for anatomic pathology services in small communities is becoming a challenge. Telecytology (TC) is defined as the electronic transmission of cytological digital images, and allows for the collection of samples, primary diagnosis, and other applications without the physical presence of a pathologist. Our aim is to systematically report, summarize, and critically analyze the most up to date applications of TC to thyroid nodules FNAB evaluation.

METHODS

We performed a systematic literature review by searching PubMed, Embase, and Cochrane Library databases. Only studies published in peer-reviewed scientific journals were included. Data were extracted using the PICO framework and critically analyzed. PRISMA guidelines were applied, and the risk of bias in the included studies was assessed using the ROBINS-I tools. The methodological quality was assessed following GRADE criteria.

RESULTS

We included 13 observational studies, resulting in a total of 3856 evaluated FNAB specimens. The majority of studies (63.6%) showed an excellent concordance rate of diagnosis via TC and conventional cytology. TC can be used to perform preliminary assessment of samples with a concordance rate ranging from 74 and 100%, showing a significant reduction of the non-diagnostic rate. Image quality was referred to as perfect or nearly perfect in most cases, regardless of telecytology technique.

CONCLUSION

Telecytology could be a valuable implementation for thyroid FNAB evaluation both for primary diagnosis and preliminary assessment of samples.

American Society of Cytopathology Telecytology validation recommendations for rapid on-site evaluation (ROSE)

Telecytology has multiple applications, including rapid onsite evaluation (ROSE) of fine-needle aspiration (FNA) specimens. It can enhance cytopathology practice by increasing productivity, reducing costs, and providing subspecialty expertise in areas with limited access to a cytopathologist. However, there are currently no specific validation guidelines to ensure safe practice and compliance with regulations. This initiative, promoted by the American Society of Cytopathology (ASC), intends to propose recommendations for telecytology implementation. These recommendations propose that the validation process should include testing of all hardware and software, both separately and as a whole; training of all individuals who will participate in telecytology with regular competency evaluations; a structured approach using retrospective slides with defined diagnoses for validation and prospective cases for verification and quality assurance. Telecytology processes must be integrated into the laboratory's quality management system and benchmarks for discrepancy rates between preliminary and final diagnoses should be established and monitored. Special attention should be paid to minimize discrepancies that downgrade malignant cases to benign (false positive on telecytology). Currently, billing and reimbursement codes for telecytology are not yet available. Once, they are, recommendation of the appropriate usage of these codes would be a part of the recommendations. These proposed guidelines are intended to be a resource for laboratories that are considering implementing telecytology. These recommendations can help to ensure the safe and effective use of telecytology and maximize its benefits for patients.

The current practice of telecytology for rapid on-site evaluation (ROSE): Practical considerations and limitations

Advances in digital imaging technology and development of high-speed internet has brought a change in ROSE practice from the traditional in-person to remote evaluation. The rapid expansion of image-guided procedures to obtain tissues for diagnosis and ancillary testing has put a huge demand on cytopathologists' time to perform on-site adequacy assessment. The technology of transmitting digital slide images in real-time via the internet from procedure site that can be viewed remotely and provide preliminary diagnosis, has had a huge impact on the practice of ROSE. Telecytology (TC) has increased the efficiency of cytopathologists, by cutting down on travel time to procedure sites and eliminate the long wait time between procedures/needle passes. It also provides the cytopathologist with the flexibility of covering ROSE procedures occurring at several locations simultaneously. The options and design of TC systems are driven by clinical needs, availability of resources and case volume. A buy-in from stakeholders early in the process, infrastructure planning and information technology (IT) support are critical for the successful implementation of TC. Training of staff, validation study and compliance training should be performed according to established guidelines. There are different TC platforms commercially available in the market today, these include static image sharing, real-time video streaming, robotic microscopy and whole slide imaging (WSI). Additionally, low-cost TC system can be built and designed using equipment that are available off-the-shelf. The intent of this review is to highlight the current practices of TC, the pros and cons of each system are discussed.

WhatsApp Messenger use in oncology: a narrative review on pros and contras of a flexible and practical, non-specific communication tool

The spread of instant messenger systems provides an excellent opportunity and a helpful tool to healthcare professionals. WhatsApp instant messenger use is widely prevalent among health professionals, cancer patients, caregivers and the general population. It is a quick and easy communication tool that may also be used on personal computers and business purposes. WhatsApp instant messenger and other similar tools may be a very useful complement for e-medicine. Instant messaging systems may be helpful, especially in rural areas, in medium- or low-income countries, or to avoid unnecessary travels, improve knowledge and awareness of cancer, monitor home care and support the delivery of home care. The unregulated use of WhatsApp instant messenger requires sound and shared guidelines to assure impeccable professional service. Although a significant number of papers have investigated the roles of social networks in connecting patients to health professionals, there is still a lack of information and scientific data about their uses, benefits and limitations in connecting health providers only for professional communication. The role of instant messenger systems in cancer practice and research needs to be clarified. In this paper, we report a focus on available data, pros and contras of the unregulated use of WhatsApp instant messaging, in the context of e-medicine, as an interprofessional and doctor/patient communication tool in oncology.

Use of Smartphones for the Detection of Uterine Cervical Cancer: A Systematic Review

Little is known regarding the usefulness of the smartphone in the detection of uterine cervical lesions or uterine cervical cancer. Therefore, we evaluated the usefulness of the smartphone in the detection of uterine cervical lesions and measured its diagnostic accuracy by comparing its findings with histological findings. We conducted a systematic review to identify studies on the usefulness of the smartphone in detecting uterine cervical lesions indexed in SCOPUS, MEDLINE/PubMed, Cochrane, OVID, Web of Science, and SciELO until November 2020. The risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 16 studies that evaluated the usefulness of the smartphone in the detection of uterine cervical lesions based on the images clicked after visual inspection with acetic acid (VIA), Lugol's iodine (VILI), or VIA/VILI combination were included in the study. Five studies estimated diagnostic sensitivity and specificity, nine described diagnostic concordance, and five described the usefulness of mobile technology. Among the five first studies, the sensitivity ranged between 66.7% (95% confidence interval (CI); 30.0-90.3%) and 94.1% (95% CI; 81.6-98.3%), and the specificity ranged between 24.0% (95% CI; 9.0-45.0%) and 85.7% (95% CI; 76.7-91.6%). The risk of bias was low (20%), and the applicability was high. In conclusion, the smartphone images clicked after a VIA were found to be more sensitive than those following the VILI method or the VIA/VILI combination and naked-eye techniques in detecting uterine cervical lesions. Thus, a smartphone may be useful in the detection of uterine cervical lesions; however, its sensitivity and specificity are still limited.

Impact of mobile devices on cancer diagnosis in cytology

BACKGROUND

Digital pathology has widened pathologists' opportunities to examine both surgical and cytological samples. Recently, portable mobile devices like tablets and smartphones have been tested for application with digital technologies including static, dynamic, and more recently whole slide imaging. This study aimed to review the published literature on the impact of mobile devices on cancer diagnoses in cytology. This analysis focused on their diagnostic potential, technical details, critical issues and pitfalls, and economical aspects.

METHODS

A systematic search was carried out in the electronic databases Embase and PubMed. Studies dealing with the application of mobile devices for diagnosing cancer on cytological specimens were included. The quality of studies was assessed with the QUADAS-2 tool. The main themes addressed were the comparison of manual examination with light microscopy and the use of mobile tools for primary diagnosis. The technical features of different models of smartphones and tablets, software, and adapters were also studied in terms of feasibility and costs-analysis.

RESULTS

Of 2458 retrieved articles, 18 were included. Concordance with light microscopy was good and diagnostic performance comparable with an expert pathologist's diagnosis. The mobile devices studied differed, sometimes significantly, in terms of speed and cost. The utility was improved by employing specifically designed adapters. Image acquisition and transmission represent the main critical points in almost all studies.

CONCLUSION

The use of mobile devices demonstrated promising results regarding the digital evaluation of cytological samples. Widespread adoption even in underserved areas is anticipated following validation studies, technology improvements, and reduction in the costs.

Smartphone adapter time trial analysis: A low-cost, time-efficient method to disseminate quality photomicrographs at the microscope

BACKGROUND

Within the field of pathology there is a need for a uniform low-cost option for securing high-quality photomicrographs. Advances in smartphone photography and 3D-printing technology allow for custom adapters to be designed for the purpose of photomicrograph capture.

METHODS

Photomicrograph acquisition was performed using four core modalities: a novel 3D-printed smartphone-to-microscope adapter, freehand smartphone-to-microscope technique, a commercial adaptor (LabCam Pro), and a microscope-mounted digital camera. Eight skin diagnoses were photographed using each of the modalities and time to image capture was measured. The photomicrographs were blindly reviewed by two academic dermatopathologists and one pathologist using a side-by-side comparison technique to determine the image quality. Cost assessments were evaluated by obtaining free pricing information on manufacturer websites.

RESULTS

The 3D-printed adapter was the most efficient method of capturing a high-quality photomicrograph in addition to being budget neutral. The microscope-mounted camera produced the highest quality photomicrographs followed by the 3D-printed adapter.

CONCLUSIONS

The 3D-printed smartphone-to-microscope adapter offers a low-cost, time-efficient method of capturing high-quality photomicrographs.

A Novel "Work from Home Setup" for Telepathology Second Opinion of Oral Lesions

The advent of smartphones with high-resolution cameras has opened up new possibilities in the field of telepathology for a second opinion especially in the COVID-19 era. The aim of this study was to evaluate the intraobserver concordance of a novel “work from home setup” with conventional microscopy diagnosis taken as the gold standard. A total of 90 cases of oral biopsies diagnosed by one pathologist were photographed with a smartphone camera. The static images were transferred via Google Drive and viewed on a 40-inch LED television screen connected by an HDMI cable to a laptop by the same pathologist. A wash-off period of 4 months was provided to avoid recall bias. The intraobserver concordance of Google Drive transfer and conventional microscopy was calculated. The cases in which the conventional slide microscopy and smartphone image diagnosis (SPID) via Google Drive were concordant constituted 98.9% (89/90), and the ones with discordant diagnoses made up 1.1% (01/90). Smartphone-assisted telepathology can be useful for a second opinion. The images can be stored on a Google Drive and then downloaded to a personal computer and viewed on large-screen television to attain high levels of diagnostic accuracy.

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

BACKGROUND

Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system-level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs.

OBJECTIVE

We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation.

METHODS

A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research.

RESULTS

In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions.

CONCLUSIONS

Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.

Implementation of pre-captured videos for remote diagnosis of cervical cytology specimens

OBJECTIVE

The objective of this study was to investigate the feasibility of implementing short videos captured by static telecytological applications for remote evaluation of cervical smears prepared by means of liquid-based cytology.

METHODS

The study was performed on representative short videos captured from a total of 404 cervical smears (benign, 135; atypical squamous cells of undetermined significance, 92; low-grade squamous intraepithelial lesion, 62; high-grade squamous intraepithelial lesion, 87; squamous cell carcinoma, 26; adenocarcinoma, 2) that were sent via file transfer protocol to password-protected accounts for remote review by three independent cytopathologists. In addition to diagnosis, reviewers commented on the overall digital video quality. Contributors' and reviewers' diagnoses were collected, recorded, and statistically evaluated.

RESULTS

Statistical evaluation detected no significant difference in diagnostic accuracy between cytological diagnoses based on short videos versus conventional slides. The overall interobserver agreement ranged from substantial to almost perfect with κ values of 0.74-0.91.

CONCLUSIONS

Short videos produced by static telecytology applications can be used as an alternative method for telecytological diagnosis of cervical smears, particularly for quality control purposes. It is a prompt and valid method for quality assessment and proficiency testing and can be integrated into the daily workflow. Short pre-captured videos of cervical smears can be used for rapid and accurate diagnosis, diminishing turnaround times and improving small cytology departments' quality indices. They can also be used for archiving, teleconsultation, and second opinion purposes, improving the performance of already existing static telecytology stations.

Comparison of smartphone-camera and conventional flatbed scanner images for analytical evaluation of chewing function

BACKGROUND

The two-colour mixing test is a quick method to assess chewing function (CF). The use of smartphone cameras for acquiring images may help in further simplifying the process.

OBJECTIVE

This study evaluated the reliability of smartphone-camera images of chewing gums to assess CF.

METHODS

Five test samples of a bicoloured chewing gum were produced by a single fully dentate adult volunteer. The specimens were flattened to 1-mm thick wafers. The two sides of the wafers were digitised with a conventional flatbed scanner (control) and were photographed 20 times using 8 different smartphones. The images were assessed optoelectronically to obtain the variance of hue (VoH) and subjectively by visual assessment (SA) using a categorical scale (SA1-SA5). Spearman's correlation and regression models were used for statistical analyses.

RESULTS

The intra-group variability for SA1-SA3 was <1% for all smartphones, but significantly higher than controls for SA4 and SA5 (smartphone: SA4 = 5.57%; SA5 = 8.76%; control: SA4 = 2.5%; SA5 = 0.79%). VoH was progressively lower from SA1 to SA5 for all imaging devices (r > -.97; P < .001). VoH comparisons between control and smartphone images revealed significant differences for the individual SA categories, and however, the magnitude of differences was small and non-significant when the full range of SA levels were considered. The linear mixed model regression showed significant effects for all the smartphones (P < .001) and SA levels (P < .001) in relation to the flatbed scanner values.

CONCLUSIONS

Smartphone cameras may be used to evaluate colour mixture for a bolus-kneading test, however, the precision is lower with higher degrees of colour mixing.

Remote Evaluation of Short Videos Captured by Static Telecytological Applications for Obtaining Expert Opinions

Over the last decade, cytopathology laboratories wishing to achieve an automated and seamless workflow process, to diminish turnaround times and to improve their diagnostic accuracy have successfully adopted information technologies and automation. New types of cameras and microscopes, connected to computers, have made possible image capture and transmission (telecytology). New innovative information technologies, including e-health and telemedical applications, constitute a valuable tool for interlaboratory collaboration and quality improvement. New applications are expected to enhance the opportunities for improvement in the field of cytological data management and sharing. In this article, we emphasize on the possible use of short videos captured by static telecytology applications in a modern cytopathology laboratory wishing to establish an effective interlaboratory comparison system and obtain expert opinions in diagnostically challenging cases from distant consultants with well recognized diagnostic competence and experience in the field of thyroid cytology.

Learning cytology in times of pandemic: an educational institutional experience with remote teaching

Introduction

As the coronavirus pandemic swept across national and state borders, institutions of higher learning, including cytology, began closing campuses and moving instruction online. We have described a method of remotely teaching cytology in our institution, including using the telecytology concept used with rapid onsite evaluation and remote conferencing and educational tools to conduct eCytology learning. This is a cost-effective method to transition a traditional in-classroom program into online teaching for cytology. It can also be implemented quickly.

Materials and methods

In March 2020, our cytology program developed a method for teaching cytology remotely. The distance-learning teaching method included the use of remote conferencing (Zoom platform) and learning management platforms (Canvas) to present lectures and administer tests. Remote multihead sessions were conducted by adapting the telecytology rapid onsite evaluation concept, which attaches a mobile device to the microscope to transmit live video to remote learners.

Results

When asked about their experience with online learning, the students had responded positively. All the students indicated a willingness to attend classes remotely in the future, even when the traditional in-classroom learning option is available.

Conclusions

We have presented a method for educating students remotely using existing technology that is affordable and can be implemented quickly by nearly all cytology education programs.

•

Our experience with teaching eCytology in times of pandemic can serve as a cost-effective way to transition a traditionally in-classroom program, into an online teaching in cytology. It can also be implemented quickly.

•

Remote multi-head sessions, conducted by adapting the tele-cytology ROSE concept with an attached mobile device to the microscope, is an effective approach to distance learning in times of social distancing and is a promising tool for the future cytology education.

•

The students, when asked about their experiences with online learning, responded positively.

Telemedicine in the Era of Coronavirus Disease 2019 (COVID-19): A Neurosurgical Perspective

Despite the substantial growth of telemedicine and the evidence of its advantages, the use of telemedicine in neurosurgery has been limited. Barriers have included medicolegal issues surrounding provider reimbursement, interstate licensure, and malpractice liability as well as technological challenges. Recently, the coronavirus disease 2019 (COVID-19) pandemic has limited typical evaluation of patients with neurologic issues and resulted in a surge in demand for virtual medical visits. Meanwhile, federal and state governments took action to facilitate the rapid implementation of telehealth programs, placing a temporary lift on medicolegal barriers that had previously limited its expansion. This created a unique opportunity for widespread telehealth use to meet the surge in demand for remote medical care. After initial hurdles and challenges, our experience with telemedicine in neurosurgery at Penn Medicine has been overall positive from both the provider and the patients' perspective. One of the unique challenges we face is guiding patients to appropriately set up devices in a way that enables an effective neuroexamination. However, we argue that an accurate and comprehensive neurologic examination can be conducted through a telemedicine platform, despite minor weaknesses inherent to absence of physical presence. In addition, certain neurosurgical visits such as postoperative checks, vascular pathology, and brain tumors inherently lend themselves to easier evaluation through telehealth visits. In the era of COVID-19 and beyond, telemedicine remains a promising and effective approach to continue neurologic patient care.

The Implementation of Static Telecytology for Teleconsultation Purposes During Preoperative Evaluation of Thyroid Fine-Needle Aspiration Specimens

Objective: The objective of this study was to investigate the impact of applying static telecytology for teleconsultation purposes during preoperative evaluation of challenging thyroid fine-needle aspiration specimens. Materials and Methods: The study was performed on 141 cytologically challenging specimens of 125 patients referred to Alpha Prolipsis Cytopathology Department. All cases were finally confirmed histologically. During the study, 10 characteristic images from each case were transferred through file transfer protocol to password-protected accounts for remote review by three independent cytopathologists, with documented experience in the field of thyroid cytology. In addition to diagnosis, reviewers also commented on overall digital image quality. Contributor's and reviewer's diagnoses were collected, recorded, and statistically evaluated. No significant difference in diagnostic accuracy could be detected between the diagnoses proffered based on digitized images and conventional slides. Telecytology is a prompt and valid method for acquisition of a second opinion diagnosis in challenging cases and can be integrated into daily workflow. The use of telecytology for teleconsultation purposes in the laboratory's daily workflow will further ensure the accuracy of preoperative cytological diagnoses and will contribute to cytopathologists continuous education and better understanding of the criteria applied in thyroid gland lesions cytomorphological diagnosis. Results: Statistical evaluation of cytological diagnoses detected no significant difference in diagnostic accuracy between the diagnoses proffered based on digitized images among contributing cytopathologists. The overall interobserver agreement was very good with κ values of 0.73-0.88. Conclusions: The widespread availability of imaging technology and telecommunication enables instant access to global expert cytopathologists. Static telecytology can be used as an efficient method for acquisition of second opinion in challenging thyroid fine-needle aspiration specimens. It can be used for rapid and accurate diagnosis, by diminishing turnaround times and improving small cytology departments' quality indices.

Efficiency of Mobile Video Sharing Application (WhatsApp®) in Live Field Image Transmission for Telepathology

Telepathology is in its nascent stages in India. Video calling applications in mobile phones can be efficiently used to transmit static and live field microscopic images hastening low cost telepathology. To evaluate the efficiency of WhatsApp® Video Calling for dynamic microscopy in distant diagnosis. Thirty haematoxylin and eosin stained slides of common pathologies were retrieved from the archives of Department of Oral Pathology and Microbiology, coded with relevant history and given to three untrained investigators. The investigators then connected a mobile phone with VOIP facility to a microscope using a custom adaptor. Dynamic fields were transferred to three independent pathologists via WhatsApp® video call. The pathologists attempted to diagnose the lesion based on the live field video over their display screen (phone). Audio quality was found to be better than that of video. In 70% of the cases, pathologists could render a diagnosis (13% gave a confirmed diagnosis, 57.7% gave a probable diagnosis). The average time taken for connecting the adaptor, connecting the call to the pathologist and then receiving the diagnosis was 9:30 min. In addition, proper history taking and staining of the tissue slides were critical to arrive at the diagnosis. WhatsApp® free VOIP facility helped untrained investigators to send the live-field pathologic fields to a specialist rendering histopathological diagnosis. The factors affecting the diagnosis included network stability, clarity of images transmitted, staining quality and contrast of nuclear details of the stain. The history, clinico-pathologic correlation, transmission of static images, training of the person transmitting the images plays a vital role in rendering accurate diagnosis. Telepathology over WhatsApp® video calling could be used as an efficient screening tool to identify suspicious lesions and follow-up critical cases.

The Use of Static Telecytology for Quality Assessment Purposes in the Evaluation of Cervical Smears Prepared by Means of Liquid-Based Cytology

Objective: The objective of this study was to investigate the role of telecytology as a tool with increased quality standards in the optimal evaluation of telecytological diagnoses proffered on the basis of digitized images from cervical smears prepared by means of liquid-based cytology. Materials and Methods: The study was performed on representative digital cytological images from a total of 808 cervical smears (benign, 270; atypical squamous cells of undetermined significance, 184; low-grade squamous intraepithelial lesion, 124; high-grade squamous intraepithelial lesion, 174; squamous cell carcinoma, 52; and adenocarcinoma, 4) that were transferred through file transfer protocol to password-protected accounts for remote review by three independent cytopathologists. In addition to diagnosis, reviewers also commented on overall digital image quality. Contributor's and reviewer's diagnoses were collected, recorded, and statistically evaluated. Their reports were recorded and classified. Results: Statistical evaluation of cytological diagnoses detected no significant difference in diagnostic accuracy between the diagnoses proffered on the basis of digitized images and conventional slides. The overall interobserver agreement was almost perfect with κ values of 0.79-0.97. Conclusions: Static telecytology can be used as an alternative method for the cytological diagnosis of cervical smears, particularly in quality assurance programs. It is a prompt and valid method for quality assessment and proficiency testing and can be integrated into daily workflow. Digital images of cervical smears can be used for rapid and accurate diagnosis, by diminishing turnaround times and improving small cytology departments' quality indices.

Smartphone-Assisted Telecytopathology: An Intraobserver Concordance Study

INTRODUCTION

Telecytology is the practice of cytology at a distance. The images captured by a camera are sent to the cytopathologist at a different location who views the images and reaches a diagnosis. Recently, smartphone-assisted telepathology has been evaluated for different subspecialities of pathology including cytology for second opinion.

MATERIALS AND METHODS

For the purpose of the study, a total of 151 cases of fine needle aspiration and 10 cases of urine cytology reported by a single pathologist were retrieved from the records. The images of all the cases were captured by a trained pathologist using the primary camera of a smartphone from the ocular of a binocular microscope. The images were sent by WhatsApp to the same pathologist who had made the conventional microscopy diagnosis. The images were viewed on the smartphone screen by the pathologist who replied with the diagnosis after analysing all the images with or without digital zoom.

RESULTS

A total of 154 cases out of 161 were correctly diagnosed on smartphone-assisted telepathology (overall intraobserver concordance of 95.6%). For head and neck swellings, the concordance was 65/70 (92.9%), for breast lesions, it was 23/24 (95.8%), and for miscellaneous swellings, it was 57/57 (100%). For urine cytology, the concordance rate was 9/10 (90%).

CONCLUSION

Though the results of this study are encouraging, further improvement in the smartphone camera resolution and internet connectivity would enhance the utility of smartphone-assisted telecytopathology.

[E-health and "Cancer outside the hospital walls", Big Data and artificial intelligence]

To heal otherwise in oncology has become an imperative of Public Health and an economic imperative in France. Patients can therefore receive live most of their care outside of hospital with more ambulatory care. This ambulatory shift will benefit from the digital revolution and the development of digital health or e-health. Cancer research will also benefit with Big Data and artificial intelligence, which gather and analyze a huge amount of data. In this synthesis, we describe the different e-health tools and their potential impacts in oncology, at the levels of education and information of patients and caregivers, prevention, screening and diagnosis, treatment, follow-up, and research. A few randomized studies have already demonstrated clinical benefits. Large Big Data projects such as ConSoRe and Health Data Hub have been launched in France. We also discuss the issues and limitations of "cancer outside the hospital walls and e-health" from the point of view of patients, health care professionals, health facilities and government. This new organization will have to provide remote support "outside the walls" with care and follow-up of quality, continuous and prolonged in total safety and equity. Ongoing and future randomized clinical trials will need to definitively demonstrate areas of interest, advantages and drawbacks not only for patients, but also for caregivers, health facilities and governments.

Histologic correlation between smartphone and coloposcopic findings in patients with abnormal cervical cytology: experiences in a tertiary referral hospital

BACKGROUND

Smartphones recently have been applied in the medical setting. However, the literature evaluating the utility of smartphones in gynecologic oncology is limited.

OBJECTIVE

To evaluate the utility of a smartphone in the detection of uterine cervical lesions in patients with abnormal cervical cytology.

STUDY DESIGN

Seventy-five women with abnormal cervical cytology were enrolled. Two doctors independently inspected the uterine cervix by using smartphone or colposcopy. Images were captured using acetic acid, and biopsies were taken as standard-of-care procedures. The diagnostic performance of the smartphone for cervical intraepithelial neoplasm 1 or worse and cervical intraepithelial neoplasm 2 or worse were evaluated, and the kappa value was calculated to determine the chance corrected agreement of the histologic diagnoses based on the smartphone and colposcopic findings.

RESULTS

There was a substantial agreement between histologic diagnoses based on the smartphone and colposcopic findings, with a kappa value of 0.67 (95% confidence interval, 0.43-0.90). The sensitivity, specificity, positive predictive value, and negative predictive value of the smartphone in the diagnosis of cervical intraepithelial neoplasm 1 or worse were 0.89 (95% confidence interval, 0.79-0.96), 0.33 (95% confidence interval, 0.08-0.70), 0.91 (95% confidence interval, 0.81-0.97), and 0.30 (95% confidence interval, 0.07-0.65), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of cervical intraepithelial neoplasm 2 or worse were 0.92 (95% confidence interval, 0.81-0.98), 0.24 (95% confidence interval, 0.09-0.45), 0.71 (95% confidence interval, 0.58-0.81), and 0.60 (95% confidence interval, 0.26-0.88), respectively.

CONCLUSION

We found that there was a substantial agreement between the histologic diagnoses based on the smartphone and colposcopic findings. The smartphone seems to be useful and may be an alternative to colposcopy.

Use of Social Networks for Data Collection in Scientific Productions in the Health Area: Integrative Literature Review

Objective: To investigate evidence on the use of social networks to collect data in scientific productions in the health area. Material and method: An integrative literature review from primary studies indexed in the SciELO, PubMed, LILACS, Scopus, and Web of Science platforms. Results: 16 scientific articles were selected, of which nine focused on the use of WhatsApp; five, on the use of Facebook; and two, on employing Twitter to collect data in scientific productions. Growth was noted on the number of investigations associated to the use of social networks, although an important paradigm still exists related to the use to generate scientific evidence, resulting in a still low number of investigations on this theme. Conclusions: The health area needs to approach evermore the development of research associated to social networks, given that this would enable a viable and rapid intervention in obtaining responses, besides being a low cost and very promising tool for data collection.

Experience with telepathology in combination with diagnostic assistance systems in countries with restricted resources

INTRODUCTION

We describe the use of telepathology in countries with restricted resources using two diagnosis assistance systems (Isabel and Memem7) in addition to the diagnoses made by experts in pathology via the iPath-Network.

METHODS

A total of 156 cases, largely from Afghanistan, were analysed; 18 cases had to be excluded because of poor image quality.

RESULTS

Of the remaining 138 cases (100%), a responsible physician provided a tentative diagnosis for 61.6% of them. With a diagnosis from a consultant pathologist, it was then possible to make a definite diagnosis in 84.8% of cases on the basis of images taken from hematoxylin and eosin staining sections alone. The use of the diagnosis assistance systems resulted in an ordered list of differential diagnoses in 82.6% (IsabelHealth) and in 74.6% (Memem7) of cases, respectively. Adding morphological terminology reduced the list of possible diagnoses to 52.2% (72 cases, Memem7), but improved their quality.

DISCUSSION

In summary, diagnosis assistance systems are promising approaches to provide physicians in countries with restricted resources with lists of probable differential diagnoses, thus increasing the plausibility of the diagnosis of the consultant pathologist.

Utility of WhatsApp as a Tool for Tele-oncopathology for Oral Lesions

Traditional telepathology techniques like whole slide imaging and robotic microscopy are too expensive to be used in developing countries. With the advent of smartphones with high-resolution cameras and faster internet services, it is now possible to send good-quality images to pathologist for diagnosis. To study the utility of WhatsApp image transfer in the histopathological diagnosis of common oral malignant and benign lesions. A total of 100 cases of oral biopsy were included in the study. These comprised of 58 cases of squamous cell carcinoma, 33 cases of oral leukoplakia, 3 cases of oral lichen planus and 6 cases of moderate to severe dysplasia. The conventional microscopy diagnosis made by glass slide viewing was taken as the gold standard and the concordance of the WhatsApp diagnosis with the gold standard was calculated for each category of diagnosis and also for all the 100 cases. The concordance rate for squamous cell carcinoma was 96.6%(56/58). For leukoplakia, there was 100%(33/33) concordance between the WhatsApp diagnosis and conventional microscopy. The concordance rates for dysplasia (4/6) and oral lichen planus (2/3) were 66.7% each. Hence, for all the categories taken together, the overall concordance rate was 95%. A concordance rate of 95% is very encouraging; however, for routine diagnostic use in telepathology, there is still a long way to go. With the availability of better smartphone cameras and faster internet, it will be possible to send better quality images in the future. The pathologists will also learn where to draw the line and ask for glass slides for final diagnosis.

Outpatient Cancer Care Delivery in the Context of E-Oncology: A French Perspective on "Cancer outside the Hospital Walls"

In oncology, the treatment of patients outside of hospitals has become imperative due to an increasing number of patients who are older and live longer, along with issues such as medical desertification, oncologist hyperspecialization, and difficulties in financing mounting health expenditures. Treatments have become less "invasive", with greater precision and efficiency. Patients can therefore receive most of their care outside of hospitals. The development of e-health can address these new imperatives. In this letter, we describe the different e-health tools and their potential clinical impacts in oncology, as already reported at every level of care, including education, prevention, diagnosis, treatment, and monitoring. A few randomized studies have yet demonstrated the clinical benefit. We also comment on issues and limits of "cancer outside the hospital walls" from the point of view of patients, health care professionals, health facilities, and public authorities. Care providers in hospitals and communities will have to adapt to these changes within well-coordinated networks in order to better meet patient expectations regarding increasing education and personalizing management. Ultimately, controlled studies should aim to definitively demonstrate areas of interest, benefits, and incentives, for not only patients, but also caregivers (formal and informal) and health care providers, health care facilities, and the nation.

Telecytology implementation: Deployment of telecytology for rapid on-site evaluations at an Academic Medical Center

INTRODUCTION

There are limited publications that address technical and practical informatics considerations when implementing telecytology for rapid on-site evaluation (ROSE). Our aim was to share the experience of deploying telecytology for ROSE at our institution.

MATERIALS AND METHODS

Key informatics issues relevant to adopting telecytology for ROSE at our institution were appraised including workflow, information technology (IT), validation, training, and quality assurance (QA).

RESULTS

A dynamic telemicroscopy solution was selected that required trained cytotechnologists to attend on-site procedures for ROSE. For validation 60 cases were reviewed using the first camera at each facility, but only 20 cases to validate subsequent cameras. A concordance rate of >90% between ROSE interpretation performed digitally to original interpretations was required for clinical validation. After reviewing 440 cases from two comparable time periods before and after implementation, employing telecytology was shown to decrease cytopathologists' work time per ROSE case from an average of 20.95 min per case to 2.91 min per case (86% time savings). The non-diagnostic rate for traditional ROSE was 7.7% compared with 4.1% after the implementation of telecytology, and the deferral rate went from 43.6% for traditional ROSE to 44.1% with telecytology. Traditional ROSE diagnoses correlated with final diagnoses in 91.8% cases, compared to 95.5% with telecytology.

CONCLUSIONS

Challenges when implementing telecytology for ROSE included technical issues, workflow concerns, and incorporating trainees into daily practice. The end result of our implementation was the adoption of an innovative way to deliver a ROSE service that maximised efficiency for cytopathologists without compromising diagnostic performance.

International telecytology: Current applications and future potential

International telecytology can improve patient care by increasing access to regional and international expertise in cytopathology. The majority of international telecytology studies published to date have been based on static telepathology platforms. Overall concordance rates for these studies ranged from 71% to 93%. This is comparable to the concordance rates published for other studies comparing diagnoses made by digital still images to reference glass slides, which vary from 80% to 95%. Static telepathology systems are relatively cheap and easy to use, and have the potential to increase access to international experts in developing countries with limited resources. In contrast, resource-rich academic and private medical centers can use whole slide digital imaging (WSI) for telecytology consultation, though few studies have been published addressing this topic. International telepathology consultation services with digital whole slide image capabilities have been established at several academic medical centers including the University of Pittsburgh Medical Center (UPMC) and the University of California at Los Angeles (UCLA), through the UCLA Center for Telepathology and Digital Pathology. In a small series of 20 telecytology cases submitted to UCLA from 2014 to 2017 (10 gynecologic and 10 fine needle aspiration cases), a meaningful diagnosis was rendered for 100% of cases, with 100% concordance between the submitting institution, versus consultation diagnosis provided by UCLA. These limited results are promising, and in the future both WSI and static telecytology consultation may have a place serving clinical needs in different practice settings.