Telepathology - the pathologist comes by Internet

The Problem

There is no pathologist and no histology lab in Solomon Islands. Biopsies are placed into Formalin and flown about 2000km to Australia for analysis. Previously it was possible to transport the samples by regular passenger planes, but after a container broke and (pungent smelling) Formalin leaked out of it, the airline refused to take along such items. They must be transported by freight planes now, and the whole procedure takes even longer.

If the patient is from Honiara, he or she can be sent home and called in again, when the diagnosis is available. But if the patient is coming from a remote island, things are more difficult: she or he has to show up again at a later time, but if transportation is not available at that time, chances are that she or he will never be seen again. To locate the patients is almost impossible.

Help through the Internet

Hopefully these problems can be solved with telepathology. Biopsies have to be locally prepared for microscope slides. On the microscope an electronic camera is attached, and pictures of the slides are taken. The pictures, together with the necessary comments, are then sent through the Internet to a database. Pathologists can now - essentially worldwide - have a look at them and comment them. Getting several opinions is easy, if enough pathologists with Internet access take part in the project. The pathologists can ask for additional pictures (e.g. different slides, different slide positions, different magnifications, etc.), to be better able to diagnose the case. It is also possible for a pathologist to directly communicate with the microscope operator giving him or her instructions how to adjust the microscope. If the microscope is remote controllable, the expert could even directly control the microscope through the Internet.

Additionally, reference pictures of various diseases can be put into the database. Local doctors can then compare their slides with positively identified cases.

For this project the National Referral Hospital in Honiara will use the iPath Server by Prof. M. Oberholzer and K. Brauchli both from the Department of Pathology of the University of Basel, Switzerland. Unlike similar servers the iPath server is located outside the hospital's Internet firewalls, and therefore specialists from all over the world can use it with a simple browser, even if they themselves are located behind such a firewall (of their own institution).

• not only pictures, but documents and other data files can be put into the database.
• to prevent influencing the diagnosis of a new viewer, comments can be hidden until she or he has entered his or her own comments.
• access to the pictures can be restricted to a small closed group or made available to several groups.
• a chat (online-communication) with a colleague or the microscope operator is possible.
• an additional small program allows pictures to be transferred automatically from the camera to the database with frame-grabber hardware.

To make this all possible, a histology lab has to be set up first, the microscope has to be equipped with a camera, and a PC with Internet access has to be installed.

• chemicals: Formalin, alcohol, xylene, paraffin
• various glass containers
• heating plate, warming chamber, refrigerator, microtome, grinding/polishing machine, electronic camera, PC

Realisation

(Photo: K. Brauchli) Kurt Brauchli is a graduated (evolution-) biologist, who turned his interest in information technology into a second profession. He will travel to Honiara soon, to take care of setting up the necessary infrastructure. Read about his preparations and his experiences in his web diary "Our Journey to Honiara". The author has asked Mr. Brauchli a few questions by email:

Are you going to travel to Honiara together with other specialists?
Not now. But later a pathologist and a lab technician might go to Honiara to expand the laboratory, which I'm going to get started and which of course will consist of just the bare minimum. We need some experience first, because presently nobody knows what the real needs in Honiara will be. My cohabitant comes along - just on vacation. She's not interested in pathology, but may be she finds something else to do.

When will you travel to Honiara?
Departure on 28.8.2001, arrival expected on 1.9.2001

How long will you stay in Honiara?
At least one month, if more is needed and we feel like it, we'll stay longer. I have enough time at hand right now.

1. The most important part is the lab. I hope to get up a basic lab, so we can fixate, embed (in paraffin), slice, and stain tissue sections. For a start just one or two stainings. In addition local personnel should learn how to prepare coloring agents etc.
2. The work place for the doctor: here we have to set up a microscope, camera and computer so that Dr. Oberli can take pictures and make them visible to a group of pathologists through our telepathology system, so they can look at them and make a diagnosis. Further there must be a feedback path, so the pathologists can explain, which parts of the sections are important.
3. a "live" online connection over the Internet. This would allow a pathologist to get a "live" look at Dr. Oberli's sections, and steer him directly to the important parts of a section, thereby saving a lot of time. But this needs a fairly good Internet connection (36kbps and up), otherwise it will be difficult.

In short, I'd like to make it possible to get a diagnosis from a pathologist in Honiara within about 3-5 days. (2 days for the side preparation + 1 day time zone lag + 1 day until the pathologist has time to look at the pictures.)

From what I've heard from Dr. Oberli, it might get a bit difficult with 36kbps connection speed, his private email connection reaches just about 19kbps, if I remember correctly, but the hospital's access may be better.
Well, that's why I'm a bit skeptical about point 3, the online microscopy. Theoretically it would be possible to work with data rates as low as 19kbps, but I'll find out what we can handle, once I'm there.

What about a directly remote controlled microscope?
I don't think this will be feasible, and I'm not sure, it would be worth to try it.

• to get to know a new country and meet new people.
• to see if our technology and my projects are actually useful for a country like the Solomon Islands, with emphasis on useful.
• since I like to travel and wanted to go on a big journey anyway, I'm looking forward to go to a place, where most likely I wouldn't have gone otherwise (although I don't really know why not).

What worries you most?
Nothing really. - I just hope I didn't forget anything essential in the short time I had for the preparation.

May "Murphy's rule" stay away from you! :-)
I don't think it will, but I like to improvise. Otherwise I wouldn't be crazy enough to start such a project without real preparations. Something will go wrong. That's what friends with email and special knowledge are for. They all help finding a way around problems and alternatives (e.g. one is a chemist and is presently looking for alternatives to xylene, because due to it's poisonous and flammable properties it might not be allowed on board of the planned ship).

Perhaps the list of things I'll take along and their prices might be of interest:

• Microtome (slicing machine, with a weight of 15-20kg). Inherited from our institution.
• Knives, knife-holders and accessories, approx. CHF 500.- to 1500.- (I'm still hoping for donations)
• Camera (Nikon Coolpix 990): about CHF 1600.-
• Adapters, lenses and other accessories for microscopes (about CHF 1500.-)
• Consumables (coloring liquids and odds and ends): from our institution

All together, including everything, this adds up to about CHF 4000-5000. (Note by author: these costs are paid by the association "South Pacific Medical Projects").

Dr. Oberli will organize the rest of the stuff (computer, warming chamber, heat plates, etc., as well as alcohol and xylene.

Thank you very much for your answers. I hope you have a good trip to Honiara and my best wishes for your project.

Why eating more marmalade is a must in Honiara

Regarding the organizing of the required material in Honiara Dr. Oberli writes on 19.8.01:

From Australia we have to get xylene (explosive) and alcohol (we had a whole drum of it, but unfortunately the contents were used by the hospital personnel for "other purposes" and almost emptied). Transportation by plane would cost a fortune because of the special packing required, and even freight ships have special requirements for such material. We still don't know, whether the goods will arrive in time.

Paraffin blocks were ordered but the promised delivery date has passed without them showing up.

And now for something positive: I found a well padded metal seat in the lab. Upon closer inspection it turned out to be a small warming chamber: exactly what we have been looking for the histology lab. My question who was using the apparatus in the lab remained unanswered. They told me it was there from the very beginning, but was never used.. The hospital electrician had to pry open the rusted door with a bit of force, dust off the apparatus, and sure enough it was still working. It was immediately confiscated for the histology lab.

Presently I'm still looking for many glass containers, and told my wife to ask all her friends in Honiara to eat more marmalade.

This just as an illustration for the sort of problems we have here. which are unknown in Switzerland.

A donation from Germany

On 24.08.01 Kurt Brauchli writes:

We have found a donor of microtome knives. The institute of pathology of the Klinikum Hannover Nordstadt (http://www.klinikum-hannover.de/nsk/) had a lot of old, but very good, even newly sharpened knives in their cellar. I just received 10 of them and I'll take along 4 of them. (Scrap metal valued 10 DM. instead of new knives for 250.- each!)

More knives and a grinding machine are on the way and can later be shipped in the next container. Special thanks go to Prof. Ostertag from Hannover, who made the knife transfer possible.

Further I found a knowledgeable lab technician in Canada (by Internet), who knows the grinding machine in Honiara (Model Sakura, in the Japanese malaria lab) and can even supply a copy of its manual.

So all that's left to buy is the camera with accessories (power supply, slide adapter, memory cards..) with various adapters and lenses, so it will fit all microscopes in Honiara (all together about CHF 3500.-).

Arrival in Honiara

On 04.09.01 Dr. Oberli writes:

Mister Brauchli and his cohabitant have arrived [on Saturday 01.09.01] 0230 in good mood. He has already started to work [on Monday, 03.09.01] with great enthusiasm.

06.09.01:

First reports from Honiara can be found now in Kurt Brauchli's diary.

The very first digital photograph made in the new histology lab

Finally the Coral Chief brought the ethanol which was left behind in Brisbane, and Mike and his colleague can continue with their work. (Photos: H. Oberli)

On 14.09.01 Dr. Oberli writes:

Within barely two weeks Kurt Brauchli, who adjusted very well to the local conditions, has managed to build a small histology lab out of just basic items and despite many unexpected problems cropping up daily.

For a start the room assigned for the lab turned out to have a restricted electrical supply of only 4 to 5 hours a day. It went on like that, but in the end we managed to overcome all hurdles.

Yesterday the first microscopic slides were ready, the pictures of which were sent by email to the Institute of Pathology of the University of Basel. Now we are eagerly awaiting the comments of the pathologists in Basel. If this works out, the first phase of this complex project is already finished with great success! Mr. Brauchli was able to stimulate the interest of the local lab technicians and they all worked and helped with a hitherto unknown enthusiasm, which in itself is a very positive aspect. During our clinical meeting today (which takes place once a week for all clinicians) Kurt Brauchli gave talks about "A histology lab in a nutshell" and "How Telepathology came to the Solomon Islands". The Medical Superintendent declared it a historical event in the medical history of Solomon Islands!

We can write a nice story, how it all started at Dr. Andreas Osterwalder's place high above Lugano, Switzerland, and then began getting realized at Prof. Oberholzer's institute in Basel. At the beginning of June Kurt Brauchli didn't know where to look for Solomon Islands in an Atlas, and in September he already made very nice histological pictures on the other side of the globe.

The very first digital histological photograph (early stadium of appendicitis) made locally. It is a historic event not only for the Solomon Islands but for other developing countries, too. In the meantime the picture quality has been considerably improved.

We hope Solomon Telekom will provide the Internet connection for connecting directly to the telepathology database server next Monday (17.09.01).

19.09.01

Status: Internet access in the hospital is ready. The above mentioned pictures have been commented by pathologists in the meantime, and Dr. Oberi was able to insert a comment, too. The lab technicians are practicing and Kurt Brauchli spends a week on vacation in the Western Province. Next week the IT side of the project will be tackled.

26.09.01

The first "real" cases are on the telepathology server ready to be analyzed by pathologists.

01.10.01

Further reports and many more pictures can be found in Kurt Brauchli's diary.

02.10.01

Kurt Brauchli has left Solomon Islands today. He intends to come back for two weeks in December 2001.

Status report at the beginning of November 2001

Photos: H. Oberli

On 05.11.01 Dr. Oberli writes:

The local lab technicians, Ana and Mike, are working with great enthusiasm and make histological preparations, which were judged to be "good to excellent" by the Royal Brisbane Hospital. Complex problems were already tackled with international cooperation (mainly the Institute of Pathology of the University of Basel and the Krankenhaus Dresden-Friedrichstadt in Germany.) Last week alone 19 preparations were made in the laboratory without any problems. The number of 1000 preparations per year we considered to be the upper limit can most likely be easily exceeded. The computer equipment for picture processing, management and storage procured from Australia will be ready for use around mid-November. To improve the picture quality, a photo adapter for one of the microscopes has to be obtained from Switzerland. At the beginning of December Kurt Brauchli, who managed to set up a simple but amazingly good working histology lab in a very short time, will come back to Honiara for another two weeks to take care of some remaining problems. Until the end of the year we hope to bring phase A (pilot project) to an end. Despite numerous and unexpected difficulties, the result will be much better than could ever be expected. The whole project could not have been realized without the donations from Switzerland (in the form of money, material, and volunteer help) and we would like to thank everybody who contributed to its success. The Solomon Islands Government provides local staff, rooms, and part of the consumables.

Some statistics at the end of July 2002

Number of cases:

Number and location of experts: Country Experts Bangladesh 1 Germany 3 South Africa 1 Switzerland 3 Total 8
	Photo: R. Joller

March 2003 News

Kurt Brauchli returned to Honiara in February and set up a new database for the registration of all new histological slides.

The microtome knive grinder was overhauled and put into operation.

July 2003 News

Number of cases:

The new telepathology-team in Honiara:

Dr Christian Himmelberger (left) and Dr Jon Andri Lutz.

August 2003 News

Dr Rooney Jagilly is now head of the Telepathology team in Honiara.

The Telepathology office

March 2004 News

Dr Dudley Ba'erodo has joined the team.

May 2004 News

Number of cases:

In June and July 2003, a large number of cases were transferred to check tele-diagnosis against lab diagnosis.

From mid November 2003 until end of February 2004 there were computer problems and the lab was not operational for some time.

July 2004 News

Volunteer IT specialist André Brand from Switzerland helped improve the technical part of telepathology at NRH. He made the telepathology office a more pleasant place to work in by rearranging the equipment and tidying up the cables going all over the place. He revived the old PC, removed lots of viruses, trojans and spyware from the computers, put a free dangling hard drive back on its mounting rails, updated and installed programs, networked two computers for a more reliable backup of data, wrote instructions, explained everything to the users, and answered their questions.

Before...	and after...	André Brand tidied up the office
Photos A. Brand, 2004		Photo R. Jagilly, 2004

4th International Conference on Successes and Failures in Telehealth

Dr Rooney Jagilly was invited to attend the 4th International Conference on Successes and Failures in Telehealth in Brisbane, Australia, held from 22nd to 23rd July 2004. It was hosted by the Centre for Online Health of the University of Queensland. The meeting was well represented internationally by people from North and South America, Asia, Africa, Western and Eastern Europe, and of course Australasia. Only Solomon Islands was represented of all the South Pacific Islands countries. There were over fifty papers presented by lecture or poster presentations from various areas of medical specialties including rehabilitation, psychiatry, emergency medicine, cardiology, radiology, rural medicine, home care, and so on. Dr Jagilly presented on telepathology, a set up Dr Hermann Oberli started before he left the Solomons, but still strongly supported by his organization and the University of Basel. The paper presented was 'Telepathology on the Solomon Islands - a two years' experience with a hybrid Web- and email-based telepathology system' coauthored with Kurt Brauchi, Hermann Oberli, Nina Hurwitz, Martin Oberholzer. The paper detailing two years experience showed the effectiveness, viability and reliability of telepathology for clinicians. It was well received and aroused a lot of interest as there are not many experiences in this area and this project is one of the pioneers in this field. Among the papers presented on the developing countries session, the Solomon paper was voted the best presented paper and was awarded a token price in the form of an Australian souvenir pictorial book "Portrait of Australia". Dr Jagilly was pleased to attend the conference as it gave him the opportunity to meet other people in the field and get to see wide applications of telemedicine. Dr Jagilly would like to thank all those who have supported the telepathology project and made it possible for him to attend the conference. [rj]

Dr Jagilly at the presentation	The certficate	The award
Photos R. Jagilly, 2004

December 2004 News

On 06.12.04 Dr Jagilly writes:

Professor Peter Dalquen, retired cytology professor from the Basel Institute of Pathology, made a visit to the National Referral Hospital from 7th Nov to 2nd December 2004, to do some assessment of the pathology laboratory and in particular telepathology and telecytology. During his stay he experienced and saw the conditions under which the staff work. He has taught Anna and Michael, the two technicians who deal with histology and cytology, on techniques in processing, fixing, staining, and examining the slides. Peter brought syringe holders for proper fine needle aspiration, the first ones for the hospital to have and doctors to use. He gave lectures to all doctors of the hospital, the nurses at a workshop and also presented a vision for improvement and efficient laboratory service. Peter's visit is a follow-up visit to NRH since Dr Nina Hurwitz's visit last year. It is hoped that another pathologist visits next year. The country has never had a pathologist. A national on training in Papua New Guinea is expected to come back in over two years time and visits like these are very helpful to the technicians and clinicians. Telecytology can now be done from Honiara because of the improved quality of pictures and processed slides. A trial will be conducted next year in collaboration with Brisbane Pathology.

Professor Peter Dalquen...		watching how samples are cut...
Photo P.Dalquen, 2004	Photos R. Jagilly, 2004
and instructing the technicians	Focusing and...	proper settings are important
Photos P. Dalquen, 2004

April 2005 News

Dr Rooney Jagilly visits Basel.

Dr Rooney Jagilly (left) learns more about cytology from Professor Peter Dalquen
Photos R. Jagilly, 2005