Skill performance in open videoscopic surgery.

INTRODUCTION: Application of minimally invasive surgery represents the future of modern surgical care. Previous studies by our group provided a novel way for viewing open surgery using a rigid endoscope attached to charged coupled device (CCD) camera in proximity to the surgical field using a robotic arm (AESOP) and a stabilizing fulcrum (Alpha port). MATERIALS AND METHODS: This study is a follow-up to investigate the technical feasibility, advantages, and disadvantages of relying only on video images displayed on standard monitors in performing open surgical procedures instead of direct binocular eye vision. This study used two surgeons as participants with training in basic surgical skill and previous experience in performing an intestinal anastomosis in an ordinary fashion. The standard task consisted of anastomosing porcine intestine in two layers with digital viewing of the operative field. A total of 40 anastomoses (20 by each surgeon) were compared with 10 control performances using direct vision of the field. RESULTS: All the resulting anastomoses were accurate, well coapted, and fully patent with no leakage. Time for task performance was approximately twice as long (p < 0.05) with videoscopic vision as with direct vision. DISCUSSION: These findings suggest it is technically feasible to conduct open surgeries with visualization of the open surgical field limited to video display on standard monitors.

A pilot telemedicine project in the Privolzhsky District, Russia.

The geography of Russia and the complex structure of the Russian health-care system make telemedicine systems especially appropriate. The telemedicine project described here deploys a telemedicine system in Nizhny Novgorod with further integration into the Privolzhsky District telemedicine network. It started with the creation of a telemedicine center with high-speed dedicated communication links to various medical institutions in Moscow, interregional telemedicine centers, and several district hospitals in rural areas of the Privolzhsky district. In addition to this specialized network, training by telemedicine specialists from the Space Biomedical Center at Moscow State University was provided along with teleconsultations with specialists from the most advanced medical institutions in Moscow. Consultations were carried out via the interregional telemedicine center on a contractual basis. The regional telemedicine network linked nearly 78 medical sites. This system provided approximately 500 teleconsultations and 100 educational sessions within the past 3 years.

Applications of robotics in surgery.

The end of the 20th century brought an increased use of computerized technology in medicine and surgery. The development of robotic surgical systems opened new approaches in general and cardiac surgery. Two leading robotic companies, Computer Motion, Inc. and Intuitive Surgical, Inc. have developed the Zeus and Da Vinci respectively, as very effective tools for surgeons to use. Both of them consist of a surgeon console, located far from the operating table, and three robotic arms, which reproduce inside the patient's body the movements performed by the surgeon at the console. The advantages of robotic surgery over laparoscopy and open surgery include: better eye-hand coordination, tremor filtration, steadiness of camera, 3-D vision, motion scale, more degrees of freedom for instruments etc. Of course, there are also some disadvantages, like the lack of tactile feedback, long time of set up, long learning curve, high cost etc. However, the advantages seem to overcome the disadvantages and more and more operations are conducted using robots. The impact of robotics in surgery is therefore very promising and in the future it will probably open even more new ways in the surgical practice and education both in Romania and across the globe.

Real-time Internet connections: implications for surgical decision making in laparoscopy.

OBJECTIVE: To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. SUMMARY BACKGROUND DATA: Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. METHODS: Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. RESULTS: The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.

Wireless ECG monitoring by telephone.

The objective of this work was to study a wireless one channel limited (3-lead) home electrocardiogram (ECG) transmission system and ambulatory devices data transmission using telephone lines. ECG screenings were conducted in two groups. The first group consisted of construction workers examined at first aid stations at construction sites in Moscow, Russia. The second group was a selected set of patients admitted to a hospital in Tblisi, Republic of Georgia. All patients were on constant monitoring and follow-up after hospitalization. Patients themselves connected the ECG leads at home or with the help of paramedics at ambulatory stations. The ECG signals were transmitted to receiving stations where doctors interpreted them. Frequency modulation was used for ECG transmission over regular telephone lines. Of 231 readings in 74 patients--70 male and 4 female (age 21-56)--in the first group, 33 patients were abnormal. In the second group, 15 out of 165 readings in 8 patients--5 male and 3 female (age 31-70)--were abnormal. ECG screening can be significantly simplified and made widely acceptable at home and distant sites using wireless monitoring tools and telephone line transfer of the signal. This project has been implemented under the auspices of the International Telecommunication Union and the Russian Telemedicine Foundation.

Impact of varying transmission bandwidth on image quality.

The objective of this paper is to determine the effect of varying transmission bandwidth on image quality in laparoscopic surgery. Surgeons located in remote operating rooms connected through a telemedicine link must be able to transmit medical images for interaction. Image clarity and color fidelity are of critical importance in telementoring laparoscopic procedures. The clarity of laparoscopic images was measured by assessing visual acuity using a video image of a Snellen eye chart obtained with standard diameter laparoscopes (2, 5, and 10 mm). The clarity of the local image was then compared to that of remote images transmitted using various bandwidths and connection protocols [33.6 Kbps POTS (IP), 128 Kbps ISDN, 384 Kbps ISDN, 10 Mbps LAN (IP)]. The laparoscopes were subsequently used to view standard color placards. These color images were sent via similar transmission bandwidths and connection protocols. The local and remote images of the color placards were compared to determine the effect of the transmission protocols on color fidelity. Use of laparoscopes of different diameter does not significantly affect image clarity or color fidelity as long as the laparoscopes are positioned at their optimal working distance. Decreasing transmission bandwidth does not significantly affect image clarity or color fidelity when sufficient time is allowed for the algorithms to redraw the remote image. Remote telementoring of laparoscopic procedures is feasible. However, low bandwidth connections require slow and/or temporarily stopped camera movements for the quality of the remote video image to approximate that of the local video image.

Wireless telemetry and Internet technologies for medical management: a Martian analogy.

BACKGROUND: The NASA Haughton-Mars Project Base Camp on Devon Island, Canada (approximately 75 degrees north) was the site for transmission of vital signs from two "terranauts" (individuals who acted as Earthbound astronauts) back to the United States in (artificially delayed) real-time. METHODS: The subjects became "physiologic ciphers" for status monitoring using readily available technologies that affordably captured and distributed vital signs to a variety of platforms. This study of nominal monitoring and simulated medical emergency used wireless technologies and the Internet. RESULTS: Basic vital signs and images can be sent using wireless topologies and completely automated functions. Due to the lightweight transport requirements, existing low data rate connections can easily handle the volume of traffic. CONCLUSIONS: Monitoring, the health of space travelers will be an important component for both low-Earth orbiting spacecraft and long-term missions to distant planets. However, terrestrial applications represent the primary application of such technologies because the home can be a remote and hazardous environment as well.

The benefits of integrating Internet technology with standard communications for telemedicine in extreme environments.

The ability to continuously monitor the vital signs of a person can be beneficial especially if the environment is hazardous or a person simply has general health concerns. We wanted to ascertain if, by integrating the Internet, ubiquitous switching technologies and off-the-shelf tools, this "suite of services" could provide a topology to enable remote monitoring in extreme and remote locations. An evaluation of this approach was conducted at the base camp of Mount Everest in the spring of 1999. Three climbers were outfitted with wireless, wearable sensors and transmitters for 24 h as they ascended through the Khumbu Icefall toward Camp One. The physiologic data was forwarded to the receiving station at Base Camp where it was forwarded to the U.S. mainland. Two of the three devices delivered physiologic data 95%-100% of the time while the third unit operated at only 78%. According to the climbers, the devices were unobtrusive, however, any additional weight while climbing Everest must provide advantage.

A strategic vision for telemedicine and medical informatics in space flight.

This Workshop was designed to assist in the ongoing development and application of telemedicine and medical informatics to support extended space flight. Participants included specialists in telemedicine and medical/health informatics (terrestrial and space) medicine from NASA, federal agencies, academic centers, and research and development institutions located in the United States and several other countries. The participants in the working groups developed vision statements, requirements, approaches, and recommendations pertaining to developing and implementing a strategy pertaining to telemedicine and medical informatics. Although some of the conclusions and recommendations reflect ongoing work at NASA, others provided new insight and direction that may require a reprioritization of current NASA efforts in telemedicine and medical informatics. This, however, was the goal of the Workshop. NASA is seeking other perspectives and views from leading practitioners in the fields of telemedicine and medical informatics to invigorate an essential and high-priority component of the International Space Station and future extended exploration missions. Subsequent workshops will further define and refine the general findings and recommendations achieved here. NASA's ultimate aim is to build a sound telemedicine and medical informatics operational system to provide the best medical care available for astronauts going to Mars and beyond.

Heuristic evaluation of a web-based interface for internet telemedicine.

A low-cost usability engineering methodology (heuristic evaluation combined with small-scale expert assessment) is examined in the context of the design and development of a Web-based telemedicine system. Six experts - three human-computer interaction (HCI) experts and three medical-content experts - examined the Spacebridge to Russia Web site for usability. The HCI experts identified 52 interface problems using a set of ten usability criteria or heuristics; these problems ranged in severity from cosmetic to a major failure. The content experts completed a series of six simple tasks while describing their actions. The usage difficulties were related to the HCI problems identified and were primarily characterized by a mismatch of the designer model and the content expert model. This heuristic/usage methodology can provide an incremental benefit in a variety of other design activities. It is suggested herein that the combined heuristic/usage methodology should be included as a standard design component of dynamic telemedicine systems.

Applications of telemedicine in the United States space program.

Since the beginning of human space flight, NASA has been placing humans in extreme and remote environments. There are many challenges in maintaining humans in outer space, including the provision of life-support systems, radiation shielding, and countermeasures for minimizing the effect of microgravity. Because astronauts are selected for their health, among other factors, disease and illness are minimized. However, it is still of great importance to have appropriate medical care systems in place to address illness and injury should they occur. With the exception of the Apollo program, exploration of space has been limited to missions that are within several hundred miles of the surface of the Earth. At the drawn of the 21st century and the new millennium, human exploration will be focused on operation of the International Space Station (ISS) and preparation for human missions to Mars. These missions will present inherent risks to human health, and, therefore, appropriate plans must be established to address these challenges and risks. Crews of long-duration missions must become more independent from ground controllers. New systems, protocols, and procedures are currently being perfected. Application of emerging technologies in information systems and telecommunications will be critical to inflight medical care. Application of these technologies through telemedicine will provide crew members access to information, noninvasive procedures for assessing health status, and guidance through the integration of sensors, holography, decision-support systems, and virtual environments. These technologies will also serve as a basis to enhance training and medical education. The design of medical care for space flight should lead to a redesign of the practice of medicine on Earth.

The Spacebridge to Russia Project: internet-based telemedicine.

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

Use of the Internet for long-term clinical follow-up.

Use of the Internet for patient-specific consultation across international boundaries has been demonstrated. This report describes the efforts of Baylor College of Medicine and NASA to conduct a telemedicine consultation with Moscow, Russia. Consultation between Russian and American physicians was performed over the Internet with a combination of real-time and store-and-forward techniques. The clinical focus involved a 65-year old Russian scientist who had undergone mitral valve replacement in the United States 5 years earlier. Development of new activity-related chest pain, dyspnea, and intermittent atrial fibrillation led to a consultation with his American cardiologist and cardiac surgeon. Real-time video was supplemented with telephone voice communication to overcome bandwidth limitations. Prior to the video link, the patient's recent history and clinical data were made available via the Internet using file transfer protocol (FTP). The patient's medications, new electrocardiographic findings, and activity status were reviewed. Specific clinical recommendations were made as a result of this telemedicine consultation. This case illustrates the technical factors, clinical implications, and confidentiality issues related to using the Internet for telemedicine consultations and demonstrates that the Internet may provide an alternative means for long-term clinical follow-up of patients.

Survey of global telemedicine.

The number and scope of telemedicine projects and applications world-wide are growing rapidly along with exponential expansions in national and international information infrastructures and computer capabilities to support them. To track these rapid changes, the Center for Public Service Communications (CPSC) of Arlington, VA, developed the Telemedicine and Information Technologies in Health Care: Project Tracking Document for the National Aeronautics and Space Administration (NASA). This document is maintained by CPSC and frequently updated. It tracks the following areas in telemedicine and health care informatics: (1) major existing Federal grant and other assistance programs and activities; (2) legislation effecting policy in these areas; (3) projects using various technologies throughout the US; and (4) telemedicine projects/interests in other nations. This paper is a survey of international (global) telemedicine activities that are outlined in that document.

Evaluation of the acute toxicity of silahydrocarbon.

Silahydrocarbon (SHC) is a base stock for a candidate high-temperature hydraulic fluid. Because United States Air Force personnel working with SHC may be exposed to potential health hazards, a complete battery of acute toxicity tests was performed with the fluid. A single neat dose of 0.1 mL SHC into New Zealand White (NZW) rabbit eyes resulted in slight conjunctival irritation 1 hr after treatment in all unflushed eyes and one of three flushed eyes. Conjunctival irritation persisted through 24 hr but dissipated by 48 hr. Rinsing the eyes after treatment was of questionable benefit. A single treatment of 0.5 mL neat SHC to rabbit skin produced negative results for all but a single animal, which had very slight erythema at the test site 48 hr after treatment. Guinea pigs failed to exhibit a sensitization response following repeated application of SHC. A single oral dose of 5 g SHC/kg body weight given to five male and five female F-344 rats and a single dermal dose of 2 g SHC/kg body weight applied to five male and five female NZW rabbits resulted in no deaths or signs of toxic stress. Five male and five female F-344 rats were exposed to 4.8 mg/L (near limit concentration) of aerosolized SHC for 4 hr. All male rats and four female rats survived. During exposure, the animals exhibited signs of eye and upper respiratory irritation.

A health maintenance facility for space station freedom.

We describe a health care facility to be built and used on an orbiting space station in low Earth orbit. This facility, called the health maintenance facility, is based on and modeled after isolated terrestrial medical facilities. It will provide a phased approach to health care for the crews of Space Station Freedom. This paper presents the capabilities of the health maintenance facility. As Freedom is constructed over the next decade there will be an increase in activities, both construction and scientific. The health maintenance facility will evolve with this process until it is a mature, complete, stand-alone health care facility that establishes a foundation to support interplanetary travel. As our experience in space continues to grow so will the commitment to providing health care.

Toxicant distribution in the Thomas Domes.

Measurement of test article concentration distribution for light gases have been made in the Thomas Dome inhalation chambers at Wright-Patterson Air Force Base, using propane as a test agent. The method used to analyze for inhomogeneities in test article spatial distribution deliberately varies the dome operational parameters rather than requiring extreme operational stability. The variation in test article concentration is analyzed by regression to determine which operational parameters most influence the test agent distribution. Unaccounted concentration variability is assumed to be the inherent spatial variation of the test article in the dome. The propane studies indicated that the spatial variation within the dome was 6.4% of the mean and that room air temperature at the top of the dome, propane analyzer baseline stability, and dome pressure were (listed in order of decreasing importance) the variables influencing the test article distribution.