TELEPATHOLOGY BY INTERNET
Summary: A new concept for telemicroscopy has recently been introduced using the internet and conventional web browsers, with JAVA support for microscope remote control as well as image transfer and discussion (http://amba.charite.de/telemic/). The system has two major components: a telemicroscopy server, which is a computer with Internet access, connected to the automatic microscope, and the telemicroscopy client who remotely operates the microscope. The simplified telemicroscopy system allows any Internet user to become a consultant for telepathology without the acquisition of specialized hardware or software. For the inquirer seeking advice, however, this solution is still very expensive, since it requires a fully automatic microscope. The present study describes a system that can be used for conventional microscopes. A video camera mounted on a microscope with a photo tube is connected to the frame grabber or a PC. Java-based telemicroscopy software transforms the computer to an Internet server, which automatically distributes new microscope images, after manual operations, to all connected clients. Any Internet user can access the web page of the server to become a telemicroscopy client. A chat function allows for the online exchange of the written text and discuss function enable the mouse button to display an arrow to all connected clients, which highlights distinct structures of the images.
The system was optimized for simplicity, while presenting all features that are necessary to show and discuss difficult cases with any expert in the field who has Internet access. It offers a new perspective for telepathology and it is envisaged that many pathologists and scientists will use the facility to connect their personal microscopes to the Internet, forming a network for teleconsultation. To foster this development, the software described in this paper is being made freely available. Hopefully, this development will promote communication between pathologists and may thus increase the quality of diagnosis. Information on inquiry and installation of the software is available at the web site mentioned above. Telemicroscopy sessions using the telemic version for conventional microscopes can be scheduled by contacting the authors by e-mail (iver.petesen@charite.de) (J Pathol May 2000; 191: 8-14)
Comment: Telepathology, is the use of modern communication systems to perform the tasks of a pathologist from a distance. These activities can include diagnostic pathology, such as frozen section services, expert consultation, and continuing education. During the past three decades, much time, effort, and money have been spent by some of the world’s best scientists on cancer research; yet the cure remains elusive. The accurate and timely diagnosis of suspicious tissue can provide immediate benefit and relief for many people. Telepathology can play a major role in this task. For about 15 years, several universities in the United States and Europe have been practicing in this area using analog telephone lines (9.2 KB), digital lines, broad band connections (1.5 MB), and the World Wide Web. Potential application of this system includes telepresentation, remote slide preparation, remote centralized diagnosis, and telediscussion.
Using this technology via Internet to link various laboratories and to provide collaboration among pathologists has increased steadily. At the present time, many countries, including Japan, use this technology. During the last two years the advantages of telepathology have become apparent to an ever-increasing number of histopathologists. The expansion of quality control program and increasing desire for second opinions mean that a more efficient system is needed to enable different pathologists view the same samples.
A search in recent English-language medical literature (Medline, since 1995) reveals more than 250 tittles referring to telemedicine and telepathology This fast growing technology, however, still has some limitations. These include high cost, inefficient software, and lack of compatibility between telepathology systems provided by different manufacturers. Thus, currently a telepathology equipped laboratory may need to have several sets for different parts of the world. These are the major obstacles to the widespread use of telematic. Telemic systems using the Internet and an Internet Web server have been solving many of the cost and incompatibility problems.
Dr. Peterson and his colleagues in Berlin introduced a simpler Internet device that can be used anywhere with access to the World Wide Web, including Iran. In Iran, we can have selected sites at major University Hospitals where experts can serve as consultants and in turn can be equipped for international pathology consultations. The main advantage of using an internet-based system is that it is easily accessible and any pathologist with sufficient equipment can serve as a consultant.
In conclusion, telepathology has several major applications. First, it offers an immediate service to remote hospitals without a pathology department. This is particularly important in Iran as well as other countries, which lack sufficient numbers of pathologists. Second, telepathology can make second-opinion consultation simpler and more accessible. It is common practice to discuss the difficult cases with other pathologists. Third, telepathology can be used as a teaching tool in cases where autopsies are taking place in remote locations, or rare disease is of interest.
Moslem Bahadori, MD, FCCP
Consultant pathologist, NRITLD
References:
-Peterson I, et al. Telepathology
by internet. J Pathol 2000; 191 (1): 8-14.
-Wells CA, Sowter C.
Telepathology: A diagnostic tool for the Millenium? J Pathol
2000; 191 (1): 1-7. Review
-Kayser K, Kayser G. Basic
aspects and recent developments in telepathology in Europe, with
specific emphasic on quality assurance. And Quant Cytol Histol 1999;
21 (4): 319-28. Review
-Rashbass J. The impact of
information technology on histopathology. Histopathology 2000;
36 (1): 1-7. Review
CONTROVERSY IN TREATMENT OF NON-ULCER DYSPEPSIA
Summaries: In an issue of New England Journal of Medicine in 1998, two articles with controversial results on the therapy of non-ulcer dyspepsia were published in regard to eradication of H. pylori.
Mc Coll et al, from University of Glasgow (Symptomatic benefit from eradicating Helicobacter pylori infection in patients with non-ulcer dyspepsia, N Engl J Med 1998; 339: 1869) examined 916 patients with dyspepsia in a single center study during a 3-year period. Of these patients, 330 H. pylori-positive patients without organic gastric disease of the stomach were enrolled. All patients had a gastric secretory analysis under stimulation of gastrin-releasing peptide and pentagastrin. One-hundred and sixty of the 318 patients received eradication therapy with omeprazole, amoxicillin and metronidazole for 2 weeks and 158 received omeprazole alone for 2 weeks. The two groups were well matched with regard to age, sex, duration and severity of symptoms and smoking habits. A total of 308 patients (97%) were reassessed one year after start of therapy.
The severity of disease was assessed on the basis of Glasgow dyspepsia score system before and one year after therapy. The range of dyspeptic score was between 0 and 20. The mean dyspeptic score decreased from 11.4±2.2 before to 5.4±4 after one year in the omeprazole group and from 11.5±2.5 to 6.2±3.6 in eradication group (p<0.07). Fifty- three percent of patients in the Omeprazole group took drugs for their dyspeptic complaints in the second half-year compared with 43 % in the eradication group (p<0.09). Complete resolution of symptoms appeared in 21 out of 154 patients (21%) in eradication group compared with 7 out of 154 (7%) in omeprazole group (p<0.001). Among all parameters (age, sex, smoking habits, the severity and duration of symptoms, the stimulatory response of acid secretory status to pentagastrin and gastrin-releasing peptide and H. pylori CagA status) in the patients, only the duration of symptoms longer than 10 years was a predictive factor (bad risk) for the resolution of symptoms. Seven patients in both groups, who had persistent pain, and underwent endoscopy during the follow-up study, developed peptic ulcer (4 in omeprazole group and 3 in eradication group). Success rate of eradication, proved by urea breath test, was 88%.
In the other study published in the same issue, Blum et al ("Lack of effect on treating Helicobacter pylori infection in patients with non-ulcer dyspepsia" N Engl J Med 1998, 339:1875-81) in a multicenter trial, 328 H. pylori-positive patients, after one week run-in period, were randomized into two groups: One group (n=164) received eradication therapy (omeprazole and two antibiotics) and the other group (n=164) received omeprazole 2x20 mg alone for 2 weeks. Eighty-three patients were excluded for various reasons from the follow-up study (40 in eradication group and 43 from the Omeprazole group). The severity of symptoms was assessed at the run-in period, and at 6 and 12 months of treatment based on a symptom rating scale from 1(no symptoms) to 7(severe symptoms). All patients underwent a 3 and 12 months control gastroscopy with biopsy specimens taken from the antrum and corpus for urease test and histiologic studies. The activity and severity of gastritis was evaluated by per protocol analysis. Eradication rate was 79% by "intention-to-treat" analysis. The success rate of therapy in the eradication group was not different from that of the omeprazole group after one year; 27.4% versus 20.7% by intention-to-treat analysis (p=0.17) and 28.2% versus 24% by per protocol analysis respectively (p=0.45). One patient in the eradication group and 6 patients in the omeprazole group developed after one year peptic ulcer disease.
Comments: Since the discovery of Helicobacter pylori as an important pathogen1, an organism which harbors in the gastric mucosa of more than half of the world’s population2 and almost 90% of people in developing countries like Iran3, the therapy of peptic ulcer disease changed from a long-term medical acid suppression or surgical vagotomy with its occasionally occurring deleterious sequelae, to a total cure of an infectious disease by simple eradication of the bacteria. Not only the H. pylori-associated peptic ulcer disease can be cured, but also low-grade gastric lymphoma can be made to regress in the majority of patients and over a long time by H. pylori eradication. Two further important diseases, namely gastric cancer and non-ulcer dyspepsia are believed to be associated with H. pylori infection in most cases. These can be cured and atrophic gastritis may be prevented as a cause of gastric cancer or active gastritis as cause of non-ulcer dyspepsia. Non-ulcer dyspepsia is the most common disease in gastroenterology with a prevalence of 25-40% in the population of the west4 and forms the majority of consultations not only by the specialists, but also by general practitioners. An important part of the medical health services and state budget will be absorbed by the long-term care of patients with this disease. If non-ulcer dyspepsia is associated with H. pylori, its cure does not only mean saving the budget and allocating it for other medical services, but eliminates the feeling of disturbed digestion in the majority of the population during their life.
A greater prevalence of H. pylori infection was found in functional dyspeptic patients than controls5. In a randomly selected population, the prevalence of infection (in 48% of the 309 dyspeptic cases) was higher than controls (in 36% of 310 cases)6. In contrast to these studies, no association was found between H. pylori infection and dyspepsia in healthy blood donors and in many large population-based studies7-11 or its subtypes. 7,9.15 The apparent association between dyspeptic symptoms and H. pylori was accounted for by subjects with ulcer history13-14. Altered gastrointestinal motility which was found in a substantial proportion of dyspeptic patients was not related to H. pylori infection.16-20 The small difference in the prevalence of H. pylori infection between dyspeptic subjects and controls has great similarity with the publications of the last decade, in which there was a weak or negligible association between H. pylori and peptic ulcer disease compared with the control population in some areas of the world. Only therapeutic trials with eradication of H. pylori and the ensuing cure of ulcer disease made clear the important pathogenic role of H. pylori for development of peptic ulcer disease. Thus, the eradication trials on non-ulcer dyspepsia can clarify the association with H. pylori.
Two studies with the small number of patients showed a significant improvement of NUD after eradication. 21-22 Now these two very large studies reveal the low efficacy of H. pylori eradication on the course of NUD. More than 70% of H. pylori-associated NUD did not improve after eradication over the one year follow-up. In the study from Glasgow, resolution of symptoms occurred in 21% of NUD patients after eradication. Patients were all from one center and were at risk of developing peptic ulcer, while 4 of 6 patients with persistent symptoms had ulcer by endoscopic examination. The study of Blum et al was a multicenteric study, in which 133 participants from 6 countries among 3 continents (North America, Europe and Africa) were involved. From the number of patients, it can be suggested that only 3 or 4 patients from each center included in this large international study!. The heterogeneity of patient pattern with NUD is very high and the question raises, why so many centers with very few cases are chosen. The results cannot be representative for each of center population studied.
This is probably the main cause of the controversial results. The prevalence of peptic ulcer is very high in Scotland, where the Glasgow study was performed.23 Therefore, the proportion of candidates developing peptic ulcer among NUD patients is higher in Scotland than in the other regions. Therefore, the H. pylori-positive NUD patients in Glasgow would benefit from the eradication therapy.
Another aspect is the different completeness of the follow-up study in the two studies; 97% of Glasgow patients were followed up over one year, while in the study of Blum et al, 83 of 411 patients (20%) enrolled were excluded for various reasons. Are patients, who were excluded, comparable with the regard to therapy response in the two groups of study of Blum and coworkers? There is some evidence that a proportion of subjects with H. pylori infection will develop symptoms in the future24 and it is assumed that among patients with FD, a small number (probably candidates developing peptic ulcer disease) may benefit from eradication therapy.25
Nevertheless, success in the eradication of H. pylori in NUD patients depends on the proportion of patients developing peptic ulcer disease.
Sadegh. Massarrat, MD
Digestive Disease Research Center, Shariati Hospital,
Tehran, University of Medical Sciences
Tehran, Iran
massarrat@ams.ac.ir
References: