Inexpensive telecytology solutions that use the Raspberry Pi and the iPhone

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.

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.

CAREDAQ: Data acquisition device for mechanical ventilation waveform monitoring

Mechanical ventilation (MV) provides respiratory support for critically ill patients in the intensive care unit (ICU). Waveform data output by the ventilator provides valuable physiological and diagnostic information. However, existing systems do not provide full access to this information nor allow for real-time, non-invasive data collection. Therefore, large amounts of data are lost and analysis is limited to short samples of breathing cycles. This study presents a data acquisition device for acquiring and monitoring patient ventilation waveform data. Acquired data can be exported to other systems, allowing users to further analyse data and develop further clinically useful parameters. These parameters, together with other ventilatory information, can help personalise and guide MV treatment. The device is designed to be easily replicable, low-cost, and scalable according to the number of patient beds. Validation was carried out by assessing system performance and stability over prolonged periods of 7 days of continuous use. The device provides a platform for future integration of machine-learning or model-based modules, potentially allowing real-time, proactive, patient-specific MV guidance and decision support to improve the quality and productivity of care and outcomes.

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.

Leveraging Technology for Remote Learning in the Era of COVID-19 and Social Distancing

The ongoing global pandemic of coronavirus disease 2019 (COVID-19) has rapidly disrupted traditional modes of operation in health care and education. In March 2020, institutions in the United States began to implement a range of policies to discourage direct contact and encourage social distancing. These measures have placed us in an unprecedented position where education can no longer occur at close quarters-most notably, around a multiheaded microscope-but must instead continue at a distance. This guide is intended to be a resource for pathologists and pathologists-in-training who wish to leverage technology to continue collaboration, teaching, and education in this era. The article is focused mainly on anatomic pathology; however, the technologies easily lend themselves to clinical pathology education as well. Our aim is to provide curated lists of various online resources that can be used for virtual learning in pathology, provide tips and tricks, and share our personal experience with these technologies. The lists include videoconferencing platforms; pathology Web sites; free online educational resources, including social media; and whole slide imaging collections. We are currently living through a unique situation without a precedent or guidebook, and we hope that this guide will enable the community of pathology educators worldwide to embrace the opportunities that 21st century technology provides.

On Edge Computing for Remote Pathology Consultations and Computations

Telepathology aims to replace the pathology operations performed on-site, but current systems are limited by their prohibitive cost, or by the adopted underlying technologies. In this work, we contribute to overcoming these limitations by bringing the recent advances of edge computing to reduce latency and increase local computation abilities to the pathology ecosystem. In particular, this paper presents LiveMicro, a system whose benefit is twofold: on one hand, it enables edge computing driven digital pathology computations, such as data-driven image processing on a live capture of the microscope. On the other hand, our system allows remote pathologists to diagnosis in collaboration in a single virtual microscope session, facilitating continuous medical education and remote consultation, crucial for under-served and remote hospital or private practice. Our results show the benefits and the principles underpinning our solution, with particular emphasis on how the pathologists interact with our application. Additionally, we developed simple yet effective diagnosis-aided algorithms to demonstrate the practicality of our approach.

Review of different platforms to perform rapid onsite evaluation via telecytology

There is increased utilisation of cytopathology to provide a rapid onsite evaluation (ROSE) of fine needle aspiration and touch preparations of small biopsies. A well-executed ROSE procedure can significantly impact the diagnostic quality and appropriate specimen triage of procured biopsy materials. To accommodate the demand for ROSE, telecytology has been increasingly implemented to facilitate ROSE occurring remotely. Telecytology can be categorised based on camera systems including eyepiece system, camera port system and robotic microscope/whole slide image scanner system. Image sharing methods include static images, broadcast only live video streaming, teleconferencing and whole slide image management system. In this review, we will discuss the advantages and disadvantages of each of these systems and deployment considerations.

Rapid on-site evaluation using telecytology: A major cancer center experience

BACKGROUND

Rapid on-site evaluation (ROSE) with cytology preparations plays a critical role in minimally invasive procedures. The time spent by a pathologist performing ROSE is unpredictable and could be used for more cost-effective activities. The solution encountered by several institutions to address this issue is the use of telecytology (TC). This study analyzes the experience of using telecytology for ROSE in a major cancer center over a period of over 2 years.

METHODS

A retrospective analysis of all remote TC evaluations for adequacy on fine needle aspiration (FNA) and touch preparations (TP) of core biopsies (CB) performed at a major cancer center was performed. The preliminary adequacy assessment was then compared to the adequacy assessment at final diagnosis.

RESULTS

A total of 12 949 adequacy assessments were analyzed. The most common sites biopsied in our institution were lymph node, lung, and liver. There were 7725 adequacy assessments for CB (59.7%), while adequacy assessment for FNA specimens represented 40.3% (n = 5224) of the total number of specimens evaluated by ROSE. Perfect concordance between initial adequacy assessment and the adequacy assessment at final cytologic diagnosis was 93% (12 049/12 949). The final diagnosis adequacy upgrade rate was 6.7% (n = 863), and the adequacy downgrade (a specimen considered adequate on-site that was determined to be nondiagnostic on final examination) was 0.3% (n = 37).

CONCLUSIONS

TC can be easily implemented with the current technologies available. It is cost-effective and allows for better patient care with a more efficient use of the pathologist's time and laboratory resources.

Long-Range Diagnosis of and Support for Skin Conditions in Field Settings

Skin diseases are a significant cause of morbidity and mortality worldwide; however, access to dermatology services are critically limited, particularly in low- to middle-income countries (LMIC), where there is an overall shortage of physicians. Implementation of long-range technological support tools has been growing in an effort to provide quality dermatology care to even the most remote settings globally. eHealth strategies can provide realistic healthcare solutions if implemented in a feasible and sensitive way, customizing tools to address the unique needs and resource limitations of the local setting. This article summarizes the various types of telemedicine and mobile health (mHealth) tools and their practical applications and benefits for patient care. The challenges and barriers of teledermatology are discussed, as well as steps to consider when implementing a new teledermatology initiative. eHealth arguably offers one of the most flexible and realistic tools for providing critically needed access to dermatology skills in underserved LMICs.

Robotic Telecytology for Remote Cytologic Evaluation without an On-site Cytotechnologist or Cytopathologist: A Tale of Implementation and Review of Constraints

BACKGROUND

The first satellite center to offer interventional radiology procedures at Memorial Sloan Kettering Cancer Center opened in October 2014. Two of the procedures offered, fine needle aspirations and core biopsies, required rapid on-site cytologic evaluation of smears and biopsy touch imprints for cellular content and adequacy. The volume and frequency of such evaluations did not justify hiring on-site cytotechnologists, and therefore, a dynamic robotic telecytology (TC) solution was created. In this technical article, we present a detailed description of our implementation of robotic TC.

METHODS

Pathology devised the remote robotic TC solution after acknowledging that it would not be cost effective to staff cytotechnologists on-site at the satellite location. Sakura VisionTek was selected as our robotic TC solution. In addition to configuration of the dynamic robotic TC solution, pathology realized integrating the technology solution into operations would require a multidisciplinary effort and reevaluation of existing staffing and workflows.

RESULTS

Extensively described are the architectural framework and multidisciplinary process re-design, created to navigate the constraints of our technical, cultural, and organizational environment. Also reviewed are the benefits and challenges associated with available desktop sharing solutions, particularly accounting for information security concerns.

CONCLUSIONS

Dynamic robotic TC is effective for immediate evaluations performed without on-site cytotechnology staff. Our goal is providing an extensive perspective of the implementation process, particularly technical, cultural, and operational constraints. Through this perspective, our template can serve as an extensible blueprint for other centers interested in implementing robotic TC without on-site cytotechnologists.

Successful Secure High-definition Streaming Telecytology for Remote Cytologic Evaluation

BACKGROUND

The use of minimally invasive procedures to obtain material for diagnostic purposes has become more prevalent in recent years. As such, there is increased demand for immediate cytologic adequacy assessment of minimally invasive procedures. The array of different locations in which rapid on-site evaluation (ROSE) is expected requires an ever-increasing number of cytology personnel to provide support for adequacy assessment. In our study, we describe the implementation process of a telecytology (TC) system in a high case volume setting and evaluate the performance of this activity.

METHODS

We performed retrospectively an analysis of all consecutive remote TC ROSE evaluations obtained for 15 months. The specimens were evaluated using a TC system. The ROSE adequacy assessment obtained at the time of the procedure was compared to the final cytopathologist-rendered adequacy assessment when all the material was available for review, including the alcohol-fixed preparations.

RESULTS

A total of 8106 distinct cases were analyzed. TC-assisted preliminary adequacy assessment was highly concordant with the final cytopathologist-rendered adequacy assessment. Perfect concordance or accuracy was at 93.1% (7547/8106). The adequacy upgrade rate (inadequate specimen became adequate) was 6.8% (551/8106), and the initial adequacy downgrade (adequate specimen became inadequate) was <0.1% (8/8106).

CONCLUSIONS

The TC outcome demonstrates high concordance between the initial adequacy assessment and final cytopathologist-rendered adequacy assessment. Adequacy upgrades were minor but, more importantly, our results demonstrate a minimal adequacy downgrade. The process implemented effectively eliminated the need for an attending pathologist to be physically present onsite during a biopsy procedure.

Design and Validation of a Low-Cost Telepathology System

OBJECTIVE

This work sought to evaluate the precision and repeatability of a telepathology prototype based on open software and hardware.

MATERIALS AND METHODS

A prototype was designed with application in telepathology and telemicroscopy. Accuracy and prototype precision were evaluated by calculating the mean absolute error and the intraclass and repeatability correlation coefficients for a series of 190 displacements at 10, 25, 50, 75, and 100 μm.

RESULTS AND CONCLUSIONS

This work developed a low-cost prototype that is accessible, easily reproducible, implementable, and scalable; based on the use of technology created under principles of open software and hardware. A pathologist reviewed the obtained images and found them to be of diagnostic quality. Its excellent repeatability, coupled with its good accuracy, allows for its application in telemicroscopy and static, dynamic, and whole-slide imaging pathology systems.

Mobile Technology for the Practice of Pathology

Recently, several technological advances have been introduced to mobile phones leading some people to refer to them as "smartphones." These changes have led to widespread consumer adoption. A similar adoption has occurred within the medical field and this revolution is changing the practice of medicine, including pathology. Several mobile applications have been published for dermatology, orthopedics, ophthalmology, neurosurgery, and clinical pathology. The applications are wide ranging, including mobile technology to increase patient engagement, self-monitoring by patients, clinical algorithm calculation, facilitation between experts to resource-poor environments. These advances have been received with mixed reviews. For anatomic pathology, mobile technology applications can be broken into 4 broad categories: (a) educational uses, (b) microscope with mobile phone, (c) mobile phone as microscope/acquisition device, and (d) miscellaneous. Using a mobile phone as an acquisition device paired with a microscope seems to be the most interesting current application because of the need for expert consultation with resource-poor environments. However, several emerging uses for mobile technology may become more prominent as the technology matures including image analysis, alternative light sources, and increased opportunities for clinician and patient engagement. The flexibility represented by mobile technology represents a burgeoning field in pathology informatics.

A low-cost real color picker based on Arduino

Color measurements have traditionally been linked to expensive and difficult to handle equipment. The set of mathematical transformations that are needed to transfer a color that we observe in any object that doesn't emit its own light (which is usually called a color-object) so that it can be displayed on a computer screen or printed on paper is not at all trivial. This usually requires a thorough knowledge of color spaces, colorimetric transformations and color management systems. The TCS3414CS color sensor (I2C Sensor Color Grove), a system for capturing, processing and color management that allows the colors of any non-self-luminous object using a low-cost hardware based on Arduino, is presented in this paper. Specific software has been developed in Matlab and a study of the linearity of chromatic channels and accuracy of color measurements for this device has been undertaken. All used scripts (Arduino and Matlab) are attached as supplementary material. The results show acceptable accuracy values that, although obviously do not reach the levels obtained with the other scientific instruments, for the price difference they present a good low cost option.

Accuracy of cytotechnologist evaluation of specimen adequacy and screening interpretation of malignancy in fine-needle aspiration of the liver

OBJECTIVE

To evaluate the performance of cytotechnologists in assessing the adequacy and accuracy of the preliminary diagnosis for fine-needle aspirates of the liver.

STUDY DESIGN

We retrospectively analyzed 10 years of data and found 589 cases of ultrasound-guided fine-needle aspiration (FNA) of the liver with on-site evaluation of adequacy (OSEA). All the OSEA were performed by the cytopathologist because OSEA of liver FNA is not performed by cytotechnologists at our institution at present. After OSEA, the material was seen by cytotechnologists who rendered an adequacy assessment and preliminary diagnosis. We calculated the adequacy and accuracy statistics and compared the performance of the cytotechnologists with the OSEA and final interpretation.

RESULTS

There was no statistically significant difference in adequacy downgrade rate for cytotechnologist versus cytopathologist assessment during the study period (5 vs. 3%, p = 0.06). A total agreement of 88% was noted in overall diagnosis with 97% agreement in malignant cases.

CONCLUSION

Cytotechnologists assess the adequacy of liver FNA accurately and there is therefore potential for them to perform OSEA for liver FNA.