Diagnostic Reliability of In-Person Versus Remote Dermatology: A Meta-Analysis.

Background:Studies comparing teledermatology with in-person dermatologists report wide variations in diagnostic agreement. Teledermatology studies should have two independent in-person consultations establishing a baseline for comparing diagnoses made face-to-face and those made remotely.Objective:To perform a meta-analysis of comparison studies having two in-person dermatologists and at least one remote dermatologist examining the same patients to determine the overall preponderance of agreement.Method:Studies having two in-person diagnosticians were identified from previous teledermatology research reviews and independent searches of PubMed and other databases. Data from six studies identified were meta-analyzed.Results:Some studies showed high levels of diagnostic concordance, while others did not. Meta-analysis revealed that concordance rates reported in the teledermatology and clinical (in-person) consultations were significantly different (odds ratio = 0.55 [Mantel-Haenszel, fixed effect model, 95% confidence interval = 0.42-0.72], χ2 = 11.87, p < 0.05, I2 = 58%). Overall results showed that in-person primary diagnoses are significantly more concordant than remote. The results also suggest that diagnoses made in-person and teledermatology were marginally but significantly different than remote.Conclusion:Although the results of this study suggest teledermatology diagnoses are less reliable than those in-person, there are still valid reasons for using teledermatology to improve access, reduce costs, and triage patients to determine those warranting further in-person consultation and/or laboratory tests. More caution should be exercised in teledermatology when diagnoses involve risky skin conditions. There is evidence that this happens in practice.

Diagnostic Laboratory Tests for COVID-19 in US: Methodology and Performance.

Background: COVID-19 is a global pandemic caused by a new coronavirus strain. Innovative tests have been developed to diagnose and characterize the spread of COVID-19. Only a few studies have reported the diagnostic value of currently available tests. The diagnostic performance of the tests is a major concern after the recent resurgence in COVID-19. Methods: Published papers and FDA data on the currently available tests were used for analysis. Likelihood ratios, and predictive values of tests were computed. Only FDA approved tests were included. RT-PCR performance among different specimen types were also explored. Main results: All the published reports on the COVID-19 tests reported RT-PCR as the validation tool for their results. Not all available COVID-19 tests reported their sensitivity and specificity. Among the publications which reported, the positive likelihood ratio ranged between 0.15 to 0.88 and tests had high negative likelihood ratio (0.99). Conclusion: Although most recent publications showed high positive and negative likelihood ratios and high predictive values, the publications on test accuracy and validity have limited scope primarily due to their small sample size and insufficiencies in methodology and published data. Although most lab tests reported high sensitivity and specificity, false omission and false discovery rates were found notable in several COVID-19 lab tests. These results suggest need for caution on test results' interpretation. Practitioners also need to integrate evidence that is evolving rapidly.

Selenium, copper, zinc and hypertension: an analysis of the National Health and Nutrition Examination Survey (2011-2016).

BACKGROUND: Hypertension is a major cardiovascular illness worldwide with many underlying causes. The role of trace elements selenium, copper, and zinc in hypertension is uncertain. The objective of this study was to evaluate the role of these trace elements in hypertension. METHOD: Data from 6683 National Health and Nutrition Examination Survey (NHANES) participants from 2011 to 2016 were analyzed using Statistical Analytical System (SAS, version 9.4) software for the role of trace elements in hypertension in age range 8 to 80 years, irrespective of the antihypertensive medication taken. Recent American Heart Association guidelines and pediatric practice guidelines for hypertension were used. RESULTS: Findings showed a significant positive association between serum selenium levels and hypertension but not serum zinc and copper. At optimal levels for transport and distribution, serum selenium levels of 120 µg/L or higher (reference level 70-150 µg/L) were significantly associated with hypertension (OR = 1.46, 95% CI = 1.29-1.66) after adjusting for confounding factors. At serum selenium level greater than 150 µg/L, the association with hypertension strengthened (OR = 1.69, 95% CI = 1.32-2.17). CONCLUSION: A positive association was found between serum selenium and hypertension, irrespective of age or anti-hypertensive medications intake. These findings also suggest that the reference levels of serum levels in healthy individuals may need to be re-determined, if supported by additional studies. If validated, patients with hypertension may also need to be cautioned about selenium intake.

The Effectiveness of Mobile Phone-Based Text Messaging to Intervene with Problem Drinking in Youth and Younger Adult Population: A Meta-Analysis.

Background: Mobile phone-based text messages have been used to address alcohol use disorder in younger populations by promoting abstinence, decreased alcohol intake, and moderation. Methods: A meta-analysis was conducted to summarize the effectiveness of mobile phone text messaging to address problem drinking by youth and younger adults. Results: Authors systematically searched PubMed, Embase, CINAHL, Web of Science, APA PsycNET, and the Cochrane Central Registry of Controlled Trials for literature published in the past 8 years (2010-2018). Randomized control trials and pre-post studies of younger people that used the problem drinking criteria of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) were included in the meta-analysis. Conclusions: The meta-analysis suggests that text message-based interventions might not be effective in decreasing alcohol intake in the younger populations.

Effects of summer internship and follow-up distance mentoring programs on middle and high school student perceptions and interest in health careers.

BACKGROUND: Minorities are underrepresented in health professions and efforts to recruit minority students into health careers are considered a way to reduce health disparities. There is little research about the effectiveness of these programs, other than satisfaction. This study aimed to measure program effects on student understanding of and interest in health careers. METHODS: Students took a career interest inventory, completed a scale measuring their self-reported understanding and interest in health careers, and wrote essays about health careers before and after completing a 1 week on campus internship on health careers and after a 9 month follow up distance mentoring program where they continued to interact with university faculty by videoconference about career options. Changes in inventory, scale, and essay scores were analyzed for changes over time using Wilcoxon and Mann-Whitney tests. RESULTS: Inventory scores were unchanged over time, but scale and essay scores trended upward significantly post internship and mentoring. CONCLUSION: Health career education and mentoring programs can positively affect student knowledge of health careers and their attitudes about them. The study's methods extend measures of program impact beyond satisfaction.

Patient and Provider Satisfaction with Teledermatology.

BACKGROUND: There is little research comparing dermatologist and patient satisfaction with in-person, store-and-forward, and live interactive examinations. OBJECTIVE: To compare satisfaction with in-person examinations to store-and-forward and live interactive consultations having two types of video. METHODS: A controlled study was conducted where patients referred for dermatology consultations were examined in-person, by video, and by store-and-forward methods. Video changed between compressed and uncompressed on alternate clinics. Patients and dermatologists rated encounters after each examination. Dermatologists doing store-and-forward evaluations rated the quality of information provided. After experiencing all methods patients ranked their preferences. Dermatologists ranked their preferences at the end of the study. RESULTS: In-person examinations were preferred by both patients and dermatologists. Overall, satisfaction with teledermatology was still high. Patients were evenly divided in preferring store-and-forward workups or live interactive video. Dermatologists were also divided on store-and-forward and uncompressed video, but tended toward the latter. Compressed video was the least preferred method among dermatologists. LIMITATIONS: Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice. CONCLUSIONS: Patients and dermatologists prefer in-person examinations and diverge on preferring store-and-forward and live interactive when video is not compressed. The amount of video compression that can be applied without noticeable image degradation is a question for future research.

Comparing High Definition Live Interactive and Store-and-Forward Consultations to In-Person Examinations.

BACKGROUND: There is little teledermatology research directly comparing remote methods, even less research with two in-person dermatologist agreement providing a baseline for comparing remote methods, and no research using high definition video as a live interactive method. OBJECTIVE: To compare in-person consultations with store-and-forward and live interactive methods, the latter having two levels of image quality. METHODS: A controlled study was conducted where patients were examined in-person, by high definition video, and by store-and-forward methods. The order patients experienced methods and residents assigned methods rotated, although an attending always saw patients in-person. The type of high definition video employed, lower resolution compressed or higher resolution uncompressed, was alternated between clinics. Primary and differential diagnoses, biopsy recommendations, and diagnostic and biopsy confidence ratings were recorded. RESULTS: Concordance and confidence were significantly better for in-person versus remote methods and biopsy recommendations were lower. Store-and-forward and higher resolution uncompressed video results were similar and better than those for lower resolution compressed video. LIMITATIONS: Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice. There were variations in expertise between the attending and second and third year residents. CONCLUSION: The superiority of in-person consultations suggests the tendencies to order more biopsies or still see patients in-person are often justified in teledermatology and that high resolution uncompressed video can close the resolution gap between store-and-forward and live interactive methods.

Direct to Consumer Mobile Teledermatology Apps: An Exploratory Study.

BACKGROUND: Since 2012, "Direct to Consumer" mobile teledermatology apps have become more available, relinquishing many data collection tasks normally done by healthcare professionals directly to patients. INTRODUCTION: To determine user friendliness, diagnostic quality, and service of commercially available mobile teledermatology apps. MATERIALS AND METHODS: All mobile teledermatology apps available at the Apple App Store were reviewed. The two most popular mobile teledermatology apps were identified and tested together with three apps having similar functionality using a single case of a patient who was also examined by a dermatologist in-person. RESULTS: Apps varied in diagnostic scope, data gathering methods, services, rendered results, and in geographic coverage and cost. DISCUSSION: None of the apps take a history as thoroughly as recommended by textbooks. Key medical questions like current medications and allergies are not asked often. Most apps rendered concordant results, except for the one having the least thorough history taking. CONCLUSIONS: Mobile teledermatology application interfaces, services, and cost vary, with some risking medical errors and possible distribution of continuity of care. The American Telemedicine Association's guidelines for teledermatology need to address the use of direct to consumer apps. To protect consumers, app regulation, certification, or guidelines suggesting appropriate development and use might be considered.

Mobile Videoconferencing Apps for Telemedicine.

INTRODUCTION: The quality and performance of several videoconferencing applications (apps) tested on iOS (Apple, Cupertino, CA) and Android (Google, Mountain View, CA) mobile platforms using Wi-Fi (802.11), third-generation (3G), and fourth-generation (4G) cellular networks are described. MATERIALS AND METHODS: The tests were done to determine how well apps perform compared with videoconferencing software installed on computers or with more traditional videoconferencing using dedicated hardware. The rationale for app assessment and the testing methodology are described. RESULTS: Findings are discussed in relation to operating system platform (iOS or Android) for which the apps were designed and the type of network (Wi-Fi, 3G, or 4G) used. The platform, network, and apps interact, and it is impossible to discuss videoconferencing experienced on mobile devices in relation to one of these factors without referencing the others. CONCLUSIONS: Apps for mobile devices can vary significantly from other videoconferencing software or hardware. App performance increased over the testing period due to improvements in network infrastructure and how apps manage bandwidth.

Lessons learned from ten years of distance learning outreach.

OBJECTIVE: The study tested the efficacy of providing distance learning with real-time videoconferencing to broaden high school student knowledge of health careers. METHODS: A pilot program was tried out and extended over ten years to include other schools in four different time zones and the National Library of Medicine. Survey results, site visits, and continued school participation were used as effectiveness indicators. Student ratings, site visits, and ongoing discussions were used to evaluate critical factors in the program. RESULTS: Nine program factors contributed to success. CONCLUSIONS: Synchronous communication can be effective for outreach to special populations given appropriate infrastructure, technology, program design, and implementation.

Cloud and traditional videoconferencing technology for telemedicine and distance learning.

INTRODUCTION: Cloud-based videoconferencing versus traditional systems are described for possible use in telemedicine and distance learning. MATERIALS AND METHODS: Differences between traditional and cloud-based videoconferencing systems are examined, and the methods for identifying and testing systems are explained. Findings are presented characterizing the cloud conferencing genre and its attributes versus traditional H.323 conferencing. RESULTS: Because the technology is rapidly evolving and needs to be evaluated in reference to local needs, it is strongly recommended that this or other reviews not be considered substitutes for personal hands-on experience. CONCLUSIONS: This review identifies key attributes of the technology that can be used to appraise the relevance of cloud conferencing technology and to determine whether migration from traditional technology to a cloud environment is warranted. An evaluation template is provided for assessing systems appropriateness.

Uncompressed high-definition videoconferencing tools for telemedicine and distance learning.

Uncompressed high-definition (HD) video image quality is superior to compressed HD video provided in most commercially available videoconferencing products. Uncompressed HD videoconferencing tools provide a more immersive experience because there is no reduction of image information and, in most cases, lower latency. Four open source uncompressed video applications are reviewed that have been tested at the National Library of Medicine: three transmitting uncompressed HD video and one transmitting loosely compressed standard-definition video. The technical requirements for implementing each are described, and test results in terms of image quality, latency, and application reliability are presented. Because the hardware and bandwidth requirements for uncompressed HD video are relatively high and most applications are still under development, they are generally not ready for mass deployment. Some are, however, ready for pilot testing and experimentation in clinical settings by either those who have or anticipate having bandwidth sufficient to support them or those interested in researching the effects higher-quality video may have on diagnostic and other clinical outcomes.

Three principles for determining the relevancy of store-and-forward and live interactive telemedicine: reinterpreting two telemedicine research reviews and other research.

The Agency for Healthcare Research and Quality sponsored two telemedicine research reviews. The latest review concluded that telemedicine is most relevant to specialties, such as psychiatry and neurology, where high levels of patient interaction are crucial to assessment. Telemedicine research studies cited in the reviews having positive findings in the specialties of ophthalmology, otolaryngology, obstetrics and gynecology, gastroenterology, and cardiology and more recent research in these areas are reviewed to identify criteria other than degree of interaction for determining the appropriateness of telemedicine interventions. These criteria include congruity or the extent that procedures used in telemedicine are similar to those of in-person examination, fidelity or the degree to which the information used for assessment in remote examinations is of similar quality to that used in-person, and reliability or the consistency with which information can be gathered and transmitted.

Video medical interpretation over 3G cellular networks: a feasibility study.

OBJECTIVE: To test the feasibility of using cell phone technology to provide video medical interpretation services at a distance. MATERIALS AND METHODS: Alternative cell phone services were researched and videoconferencing technologies were tried out to identify video products and telecommunication services needed to meet video medical interpretation requirements. The video and telecommunication technologies were tried out in a pharmacy setting and compared with use of the telephone. RESULTS: Outcomes were similar to findings in previous research involving video medical interpretation with higher bandwidth and video quality. Patients appreciated the interpretation service no matter how it is provided, while health providers and interpreters preferred video. CONCLUSION: It is possible to provide video medical interpretation services via cellular communication using lower bandwidth videoconferencing technology that provides sufficient quality, at least in pharmacy settings. However, a number of issues need to be addressed to ensure quality of service.

Internet-based videoconferencing coder/decoders and tools for telemedicine.

Alternative videoconferencing technologies for providing telemedicine via the Internet are described. Background information about how digital video applications have been instantiated using Internet protocols is presented. Specific methods for encoding and decoding video are discussed and video applications that have been tested at the National Library of Medicine are reviewed. This article suggests that no one technology is best and that the appropriateness of a method depends on specific applications. Some technologies, however, have lower, more flexible bandwidth requirements and are more standardized, making them more practical. Still, emerging, yet-to-be-standardized applications offer new capabilities warranting further investigation.

Advanced networks and computing in healthcare.

As computing and network capabilities continue to rise, it becomes increasingly important to understand the varied applications for using them to provide healthcare. The objective of this review is to identify key characteristics and attributes of healthcare applications involving the use of advanced computing and communication technologies, drawing upon 45 research and development projects in telemedicine and other aspects of healthcare funded by the National Library of Medicine over the past 12 years. Only projects publishing in the professional literature were included in the review. Four projects did not publish beyond their final reports. In addition, the authors drew on their first-hand experience as project officers, reviewers and monitors of the work. Major themes in the corpus of work were identified, characterizing key attributes of advanced computing and network applications in healthcare. Advanced computing and network applications are relevant to a range of healthcare settings and specialties, but they are most appropriate for solving a narrower range of problems in each. Healthcare projects undertaken primarily to explore potential have also demonstrated effectiveness and depend on the quality of network service as much as bandwidth. Many applications are enabling, making it possible to provide service or conduct research that previously was not possible or to achieve outcomes in addition to those for which projects were undertaken. Most notable are advances in imaging and visualization, collaboration and sense of presence, and mobility in communication and information-resource use.

Communication and proximity effects on outcomes attributable to sense of presence in distance bioinformatics education.

BACKGROUND: Online learning is increasingly popular in medical education and sense of presence has been posited as a factor contributing to its success. Communication media influences on sense of presence and learning outcomes were explored in this study. Test performance and ratings of instruction and technology, factors influenced by sense of presence, are compared under four conditions involving different media and degrees of student physical presence: 1) videoconference co-located, 2) webcast co-located, 3) videoconference dispersed, and 4) webcast dispersed. METHODS: Eighty one first to forth year medical students heard a lecture on telemedicine and were asked to collaboratively search a telemedicine website under conditions where the lecture was delivered by videoconference or one way streaming (webcast) and where students were either co-located or dispersed. In the videoconference conditions, co-located students could use the technology to interact with the instructor and could interact with each other face to face, while the dispersed students could use the technology to interact with both the instructor and each other. In the webcast conditions, all students could use chat to communicate with the instructor or each other, although the co-located students also could interact orally. After hearing the lecture, students collaboratively searched a telemedicine website, took a test on lecture-website content and rated the instruction and the technology they used. Test scores on lecture and website content and ratings of instruction and technology for the four conditions were compared with analysis of variance and chi-square tests. RESULTS: There were no significant differences in overall measures, although there were on selected ratings of instruction. Students in both webcast conditions indicated they were encouraged more to follow up on their own and felt instruction was more interactive than co-located videoconferencing students. Dispersed videoconferencing students indicated the highest levels of interaction and there was evidence they interacted more. CONCLUSION: Results do not strongly support proximity as a sense of presence factor affecting performance and attitudes, but do suggest communication medium may affect interactivity.

An exploratory study of co-location as a factor in synchronous, collaborative medical informatics distance education.

BACKGROUND: This study determined differences in learning, judgments of teaching and technology, and interaction when videoconferencing was used to deliver instruction on telemedicine to medical students in conditions where they were co-located and dispersed. A lecture on telemedicine was given by videoconference to medical students at a distant site. After a question and answer period, students were then given search problems on the topic and encouraged to collaborate. Half the students were randomly assigned to a co-located condition where they received the presentation and collaborated in a computer lab, and half were assigned to a dispersed condition where they were located in different rooms to receive the presentation and collaborate online using the videoconferencing technology. Students were observed in both conditions and they individually completed a test on presentation content and a rating scale about the quality of the teaching and the technology. FINDINGS: There were no differences between the two groups in the learning outcomes or judgments about the teaching and technology, with the exception that more students in the dispersed condition felt more interaction was fostered. The level and patterns of interaction were very different in the two conditions and higher for dispersed students. CONCLUSIONS: Synchronous communication at a distance via videoconference may give sufficient sense of presence that the learning experience may be similar to that in actual classrooms, even when students are far apart. The technology may channel interaction in desirable ways.

Comparing in-person, video, and telephonic medical interpretation.

BACKGROUND: Using trained interpreters to provide medical interpretation services is superior to services provided on an ad hoc basis, but little is known about the effectiveness of providing their services remotely, especially using video. OBJECTIVE: To compare remote medical interpretation services by trained interpreters via telephone and videoconference to those provided in-person. DESIGN: Quasi-randomized control study. PARTICIPANTS: Two hundred and forty-one Spanish speaking patient volunteers, twenty-four health providers, and seven interpreters. APPROACH: Patients, providers and interpreters each independently completed scales evaluating the quality of clinical encounters and, optionally, made free text comments. Interviews were conducted with 23 of the providers, the seven interpreters, and a subset of 30 patients. Time data were collected. RESULTS: Encounters with in-person interpretation were rated significantly higher by providers and interpreters, while patients rated all methods the same. There were no significant differences in provider and interpreter ratings of remote methods. Provider and interpreter comments on scales and interview data support the higher in-person ratings, but they also showed a distinct preference for video over the phone. Phone interviews were significantly shorter than in-person. DISCUSSION: Patients rated interpretation services highly no matter how they were provided but experienced only the method employed at the time of the encounter. Providers and interpreters were exposed to all three methods, were more critical of remote methods, and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raise questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel, but other factors might have affected time results. Since the patient population studied was Hispanic and predominantly female care must be taken in generalizing these results to other populations.

Extending a Blended Education Program to Native American High School Students in Alaska.

This article describes the expansion of a blended learning program sponsored by the National Library of Medicine (NLM) that combines synchronous distance learning with face to face instruction. Background information about the program is briefly discussed and challenges to expanding the program are presented. The expansion was not merely a matter of adding a school. It involved close coordination between the NLM, existing participants and those at the candidate school. The challenges included identifying a candidate school, establishing contact and determining interest, assessing and testing connectivity, developing a calendar and schedule, and identifying faculty. Since NLM is on the east coast, the current school was on the west coast, and the candidate school was in Alaska, all of challenges were compounded by enormous distances and differences in time, but all were resolved successfully.