- Email: [email protected]
Use of Multimedia Messaging System (MMS) by Junior Doctors for Scan Image Transmission in Neurosurgery
PEER-REVIEW REPORTS
Use of Multimedia Messaging System (MMS) by Junior Doctors for Scan Image Transmission in Neurosurgery Ji Min Ling, Kim Zhuan Lim, Wai Hoe Ng
Key words 䡲 Image selection 䡲 Multimedia Messaging Service (MMS) 䡲 Neurosurgery 䡲 Referral 䡲 Teleradiology Abbreviations and Acronyms CT: Computed tomography MMS: Multimedia Messaging Service MRI: Magnetic resonance imaging Department of Neurosurgery, National Neuroscience Institute, Singapore To whom correspondence should be addressed: Wai Hoe Ng [E-mail: [email protected]] Citation: World Neurosurg. (2012) 77, 2:384-387. DOI: 10.1016/j.wneu.2011.03.023 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
INTRODUCTION Neurosurgical emergencies frequently mandate prompt, accurate diagnosis and rapid institution of appropriate therapy. Besides the clinical details such as age and level of consciousness, scan interpretation is critical in making a definitive diagnosis and formulating the management plan. With the advent of Multimedia Messaging Service (MMS) technology, the National Neuroscience Institute in Singapore has been utilizing MMS since 2006 (5), mainly for communication between neurosurgical specialist residents and the attending neurosurgeon. Relevant representative scan images are taken directly from the mobile phone from the Picture Archiving and Communications System off the computer screen using a dedicated mobile phone (with VGA camera and MMS capabilities) and transmitted to the attending neurosurgeon, followed by a telephone consultation to provide relevant clinical details. The usage rates are high, and the consultants feel that they are more comfortable with making decisions when verbal description is supplemented by MMS scan images.
384
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䡲 BACKGROUND: Multimedia Messaging Service (MMS) is used by neurosurgical residents to transmit scan images to the attending neurosurgeon in conjunction with telephone consultation. This service has been well received by the attending neurosurgeons, who felt that after viewing scan images on their phones, they felt increased confidence in clinical decision making and that it reduced the need for recall to the hospital. 䡲 OBJECTIVE: The use of MMS can be extended to junior doctors making referrals from regional hospitals with no neurosurgical cover. This study aims to validate the competency of non-neurosurgically trained junior doctors in selecting optimal images to transmit via MMS to the attending neurosurgeon on call. 䡲 METHODS: Ten junior doctors with no formal neurosurgical training and five neurosurgical residents were interviewed. They were shown the full complement of images together with relevant clinical history and assessment. They were then asked to make the radiological diagnosis and then select two images for MMS transmission to the attending neurosurgeon that they thought would best aid the neurosurgeon in clinical decision making. The attending neurosurgeon was asked to comment, on each image, whether his management plan would differ if he was shown the entire series of the images. 䡲 RESULTS: All the images chosen are deemed appropriate, and the decision made based on the MMS images would be similar if the entire series of images were available to the neurosurgeon. However, 7 of 10 junior doctors were unable to read magnetic resonance images of lumbar spine. There was no significant difference in the images chosen by the neurosurgical residents and the junior doctors. 䡲 CONCLUSION: It is feasible and safe for junior doctors to utilize MMS to transmit computed tomographic images to a neurosurgeon while making an urgent referral. The images selected are representative of the disease pathology and facilitate clinical decision making.
Neurosurgery, as a highly specialized service, is generally only available in specialized tertiary hospitals. Referrals from regional hospitals have relied heavily on verbal description of the clinical and scan findings usually by fairly junior doctors. Some of these doctors are not familiar with the interpretation of brain scans, and incorrect description of scan findings can potentially lead to erroneous diagnosis and inappropriate management (8). Alternatives of image-transferring systems such as email, Integrated Service Digital Net-
work, and other techniques have been suggested (1–3, 6, 7). These strategies are certainly useful and have been used for the assessment of the need for interhospital transfer of neurosurgical patients. The disadvantages of such strategies lie in the need for costly equipment, more intensive training, and a static workstation to view incoming images. Aim The aim of the study is to validate if junior doctors are competent in choosing the right
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.03.023
PEER-REVIEW REPORTS JI MIN LING ET AL.
images to send via MMS to the neurosurgeon on call.
MATERIALS AND METHODS Ten medical officers who have no formal neurosurgical training and five neurosurgical residents were interviewed. They were shown 10 cases (Figure 1), beginning with a clinical scenario and followed by the full complement of relevant computed tomography (CT) or magnetic resonance (MR) images. The cases selected for this study comprised common neurosurgical emergencies that require prompt intervention. The junior were asked to make a radiological diagnosis and then select two images to transmit to the neurosurgeon via MMS that would best support the diagnosis and aid the neurosurgeon in clinical decision making. The images (Figure 2) were col-
USING MMS FOR SCAN IMAGE TRANSMISSION
lated and reviewed by an attending neurosurgeon. The neurosurgeon who reviewed the images was blinded from knowing the identity of the candidate (i.e., neurosurgical residents or non-neurosurgically trained doctor). The neurosurgeon was asked to comment if the images selected were sufficient to formulate a management plan and whether the plan would differ if the full complement of scans was visualized. The answer was either yes (1) or no (0). The score for each candidate range from 0 to 10.
groups were found to be statistically not significant (P ⫽ 0.50). This showed that non-neurosurgically trained doctors were as capable as neurosurgical residents in identifying a gross lesion on a brain CT scan. Seven of 10 junior doctors were unable to read MR images of the lumbar spine, whereas 5 of all 5 neurosurgical residents could interpret spinal MR images (P value⫽0.0186, Fisher’s exact test). One of the 10 junior doctors was unable to recognize hydrocephalus; hence, no image was chosen for the hydrocephalus case.
RESULTS The profiles of the junior doctors are summarized in Table 1. The average scores for the two groups of candidates are shown in Table 2. By applying the Student t test, the differences in the means between the two
Figure 1. Descriptions of the 10 cases used during interview with the doctors.
WORLD NEUROSURGERY 77 [2]: 384-387, FEBRUARY 2012
DISCUSSION The use of MMS in sharing scan information among neurosurgical colleagues is common in our institution. It is a very useful tool in communication, as a picture speaks a thousand words. It was therefore interesting to find out if non-neurosurgically trained doctors were capable of using this tool when making urgent referrals. Normally, one or two representative images are adequate for making diagnoses in common neurosurgical emergencies such as large intracranial hematoma and hydrocephalus. The aim of this study was therefore to find out if a nonneurosurgically trained doctor could select a representative image from a series of images that best describes the lesion or pathology. The results of this study validated that junior doctors (who are not neurosurgically trained) are competent in selecting the appropriate images to send via MMS when making urgent referrals. The use of MMS allows the neurosurgeon to see the CT/MRI images even when he or she is not in the hospital. Having seen the scan earlier helps the neurosurgeon to set his or her priorities and enable early surgical planning. It takes less than 5 minutes (4) for the images to be captured, transmitted, and received by the neurosurgeon. This method is therefore a simple, rapid, and useful tool in emergency situations. The immediate and prompt institution of definitive measures such as surgery will in turn lead to lower mortality and morbidity. During the interview of junior doctors, we observed that they recognized abnormalities on brain CT scans mainly by looking for hyperdense lesions as well as asymmetry. Selections of images were based on
www.WORLDNEUROSURGERY.org
385
PEER-REVIEW REPORTS JI MIN LING ET AL.
USING MMS FOR SCAN IMAGE TRANSMISSION
Figure 2. Images chosen by the 15 doctors who were interviewed. The non-neurosurgically trained doctors are rows (from the top) 1, 3, 4, 5, 6, 8, 9, 10, 11, and 12. The neurosurgical residents are rows (from the top) 2, 7, 13, 14, and 15.
386
www.SCIENCEDIRECT.com
the widest diameter of the lesion or the greatest midline shift. The majority of the junior doctors were not confident in postulating the underlying pathologies (e.g., hemorrhage, tumor) and were also not conversant with providing a succinct verbal description of the lesion. This further substantiates our belief that the availability of MMS can significantly overcome this weak link of scan interpretation in the process of neurosurgical referral. Nevertheless, the use of MMS or any form of remote transmission of images does not obviate the need for formal clinical assessment and physical examination. MMS is not useful when the lesion is small, because the size and resolution of the image is greatly reduced on a mobile phone screen. Examples are small subarachnoid hemorrhage and early hydrocephalus, where only the temporal horns of the lateral ventricles are more prominent. Neurosurgeons therefore have to be aware of this pitfall when interpreting MMS images. Fundamentally, in any situation where scan findings do not correlate with clinical neurology, further assessment is mandatory. In our study, we identified two problems with MRIs of the spine. First, the fine details of MRIs could not be shown very well on a mobile phone screen. Second, interpretation of spinal MRI is a specialized skill. Only 3 of 10 non-neurosurgically trained doctors could read lumbar spine MRIs. The number of years of working experience does not correlate with the ability to read MRIs of the spine. Not surprisingly, the three doctors who could read MRIs of the lumbar spine had experience working in neurology and orthopedic surgery. The neurosurgeon on call normally decides, based on the specific clinical situation, if he or she needs to see the scan image after a phone consult. When required, he or she could ask the referring doctor to use a camera phone to capture a photograph of the image showing the lesion and then send the image via MMS. This process takes less than 5 minutes to complete. To safeguard patients’ confidentiality, we recommend sending images without tagging the identity of the patients in the MMS. The patient’s identity could be given to the neurosurgeon on call during the phone consult. Alternatively, it could be sent out in a different message/text following the MMS.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.03.023
PEER-REVIEW REPORTS JI MIN LING ET AL.
USING MMS FOR SCAN IMAGE TRANSMISSION
Table 1. Profile of the Junior Doctors Interviewed No.
Postinternship Year
Current Department
Previous Departments
1
1
Psychiatry
GM, GS, O&G (Internship)
2
1
General surgery
GM, GS, Ortho (Internship)
3
1
General surgery
GM, GS, Ortho (Internship)
4
1
General medicine
GM, GS, Ortho (Internship)
5
1
Gastroenterology
GM, GS (Internship)
6
2
Respiratory medicine
A&E, GM
7
2
Infectious disease
Cardiology, GM, infectious disease
8
3
General medicine
Neurology, cardiology, respiratory medicine, GM
9
4
Infectious disease
GM, geriatrics, respiratory medicine, anesthesia
10
5
Anesthesia
GM, GS, Peds, Ortho, A&E, anesthesia
GM, general medicine; GS, general surgery; O&G, obstetrics and gynecology; Ortho, orthopedic surgery; A&E, accident and emergency department; Peds, pediatrics.
CONCLUSION It is feasible and safe for junior doctors to utilize MMS to send brain CT images to the neurosurgeon on call while making an ur-
Table 2. Average Score of Neurosurgical Resident Versus NonNeurosurgically Trained Doctors Average (Excluding Average Spine) Neurosurgical resident
10/10
9/9
Non-neurosurgically trained doctor
9.2/10
8.9/9
gent referral. Junior doctors with no formal neurosurgical training are shown to be capable of identifying common lesions on brain CT scans encountered during neurosurgical emergencies. The images selected represented the pathology accurately and will be a useful adjunct in the neurosurgical referral process. Our study however showed a distinct deficiency in the interpretation of spine imaging, which deserves further study in the future.
2. Houkin K, Fukuhara S, Selladurai BM, Zurin AA, Ishak M, Kuroda S, Abe H: Telemedicine in neurosurgery using international digital telephone services between Japan and Malaysia: technical note. Neurol Med Chir (Tokyo) 39:773-778, 1999. 3. Kurasti H, Peponen J, Tervonen O, Kuutti K: The teleradiology system and changes in work practices. Comput Methods Programs Biomed 57:69-78, 1998. 4. Ng WH, Wang E, Bernstein M: Teleradiology and emergency neurosurgery—presence in a small Asian city state and need in a large Canadian province. J Brain Dis 1:7-11, 2009. 5. Ng WH, Wang E, Ng I: Multimedia messaging service teleradiology in the provision of emergency neurosurgery service. Surg Neurol 67:338-341, 2007. 6. Poon WS, Goh KY: The impact of teleradiology on the interhospital transfer of neurosurgical patients and their outcome. Hong Kong Med J 4:293-295, 1998. 7. Singh R, Ng WH, Lee KE, Wang E, Ng I, Lee WL: Telemedicine in emergency neurological service provision in Singapore: using technology to overcome limitation. Telemed J E Health 15:560-565, 2009. 8. Walters KA: Telephoned head injury referrals: the need to improve the quality of information provided. Arch Emerg Med 10:29-34, 1993.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. received 7 September, 2010; accepted 22 March 2011 Citation: World Neurosurg. (2012) 77, 2:384-387. DOI: 10.1016/j.wneu.2011.03.023
REFERENCES 1. Goh KY, Lam CK, Poon WS: The impact of teleradiology on the interhospital transfer of neurosurgical patients. Br J Neurosurg 11:52-56, 1997.
WORLD NEUROSURGERY 77 [2]: 384-387, FEBRUARY 2012
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
387
Use of Multimedia Messaging System (MMS) by Junior Doctors for Scan Image Transmission in Neurosurgery Ji Min Ling, Kim Zhuan Lim, Wai Hoe Ng
Key words 䡲 Image selection 䡲 Multimedia Messaging Service (MMS) 䡲 Neurosurgery 䡲 Referral 䡲 Teleradiology Abbreviations and Acronyms CT: Computed tomography MMS: Multimedia Messaging Service MRI: Magnetic resonance imaging Department of Neurosurgery, National Neuroscience Institute, Singapore To whom correspondence should be addressed: Wai Hoe Ng [E-mail: [email protected]] Citation: World Neurosurg. (2012) 77, 2:384-387. DOI: 10.1016/j.wneu.2011.03.023 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
INTRODUCTION Neurosurgical emergencies frequently mandate prompt, accurate diagnosis and rapid institution of appropriate therapy. Besides the clinical details such as age and level of consciousness, scan interpretation is critical in making a definitive diagnosis and formulating the management plan. With the advent of Multimedia Messaging Service (MMS) technology, the National Neuroscience Institute in Singapore has been utilizing MMS since 2006 (5), mainly for communication between neurosurgical specialist residents and the attending neurosurgeon. Relevant representative scan images are taken directly from the mobile phone from the Picture Archiving and Communications System off the computer screen using a dedicated mobile phone (with VGA camera and MMS capabilities) and transmitted to the attending neurosurgeon, followed by a telephone consultation to provide relevant clinical details. The usage rates are high, and the consultants feel that they are more comfortable with making decisions when verbal description is supplemented by MMS scan images.
384
www.SCIENCEDIRECT.com
䡲 BACKGROUND: Multimedia Messaging Service (MMS) is used by neurosurgical residents to transmit scan images to the attending neurosurgeon in conjunction with telephone consultation. This service has been well received by the attending neurosurgeons, who felt that after viewing scan images on their phones, they felt increased confidence in clinical decision making and that it reduced the need for recall to the hospital. 䡲 OBJECTIVE: The use of MMS can be extended to junior doctors making referrals from regional hospitals with no neurosurgical cover. This study aims to validate the competency of non-neurosurgically trained junior doctors in selecting optimal images to transmit via MMS to the attending neurosurgeon on call. 䡲 METHODS: Ten junior doctors with no formal neurosurgical training and five neurosurgical residents were interviewed. They were shown the full complement of images together with relevant clinical history and assessment. They were then asked to make the radiological diagnosis and then select two images for MMS transmission to the attending neurosurgeon that they thought would best aid the neurosurgeon in clinical decision making. The attending neurosurgeon was asked to comment, on each image, whether his management plan would differ if he was shown the entire series of the images. 䡲 RESULTS: All the images chosen are deemed appropriate, and the decision made based on the MMS images would be similar if the entire series of images were available to the neurosurgeon. However, 7 of 10 junior doctors were unable to read magnetic resonance images of lumbar spine. There was no significant difference in the images chosen by the neurosurgical residents and the junior doctors. 䡲 CONCLUSION: It is feasible and safe for junior doctors to utilize MMS to transmit computed tomographic images to a neurosurgeon while making an urgent referral. The images selected are representative of the disease pathology and facilitate clinical decision making.
Neurosurgery, as a highly specialized service, is generally only available in specialized tertiary hospitals. Referrals from regional hospitals have relied heavily on verbal description of the clinical and scan findings usually by fairly junior doctors. Some of these doctors are not familiar with the interpretation of brain scans, and incorrect description of scan findings can potentially lead to erroneous diagnosis and inappropriate management (8). Alternatives of image-transferring systems such as email, Integrated Service Digital Net-
work, and other techniques have been suggested (1–3, 6, 7). These strategies are certainly useful and have been used for the assessment of the need for interhospital transfer of neurosurgical patients. The disadvantages of such strategies lie in the need for costly equipment, more intensive training, and a static workstation to view incoming images. Aim The aim of the study is to validate if junior doctors are competent in choosing the right
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.03.023
PEER-REVIEW REPORTS JI MIN LING ET AL.
images to send via MMS to the neurosurgeon on call.
MATERIALS AND METHODS Ten medical officers who have no formal neurosurgical training and five neurosurgical residents were interviewed. They were shown 10 cases (Figure 1), beginning with a clinical scenario and followed by the full complement of relevant computed tomography (CT) or magnetic resonance (MR) images. The cases selected for this study comprised common neurosurgical emergencies that require prompt intervention. The junior were asked to make a radiological diagnosis and then select two images to transmit to the neurosurgeon via MMS that would best support the diagnosis and aid the neurosurgeon in clinical decision making. The images (Figure 2) were col-
USING MMS FOR SCAN IMAGE TRANSMISSION
lated and reviewed by an attending neurosurgeon. The neurosurgeon who reviewed the images was blinded from knowing the identity of the candidate (i.e., neurosurgical residents or non-neurosurgically trained doctor). The neurosurgeon was asked to comment if the images selected were sufficient to formulate a management plan and whether the plan would differ if the full complement of scans was visualized. The answer was either yes (1) or no (0). The score for each candidate range from 0 to 10.
groups were found to be statistically not significant (P ⫽ 0.50). This showed that non-neurosurgically trained doctors were as capable as neurosurgical residents in identifying a gross lesion on a brain CT scan. Seven of 10 junior doctors were unable to read MR images of the lumbar spine, whereas 5 of all 5 neurosurgical residents could interpret spinal MR images (P value⫽0.0186, Fisher’s exact test). One of the 10 junior doctors was unable to recognize hydrocephalus; hence, no image was chosen for the hydrocephalus case.
RESULTS The profiles of the junior doctors are summarized in Table 1. The average scores for the two groups of candidates are shown in Table 2. By applying the Student t test, the differences in the means between the two
Figure 1. Descriptions of the 10 cases used during interview with the doctors.
WORLD NEUROSURGERY 77 [2]: 384-387, FEBRUARY 2012
DISCUSSION The use of MMS in sharing scan information among neurosurgical colleagues is common in our institution. It is a very useful tool in communication, as a picture speaks a thousand words. It was therefore interesting to find out if non-neurosurgically trained doctors were capable of using this tool when making urgent referrals. Normally, one or two representative images are adequate for making diagnoses in common neurosurgical emergencies such as large intracranial hematoma and hydrocephalus. The aim of this study was therefore to find out if a nonneurosurgically trained doctor could select a representative image from a series of images that best describes the lesion or pathology. The results of this study validated that junior doctors (who are not neurosurgically trained) are competent in selecting the appropriate images to send via MMS when making urgent referrals. The use of MMS allows the neurosurgeon to see the CT/MRI images even when he or she is not in the hospital. Having seen the scan earlier helps the neurosurgeon to set his or her priorities and enable early surgical planning. It takes less than 5 minutes (4) for the images to be captured, transmitted, and received by the neurosurgeon. This method is therefore a simple, rapid, and useful tool in emergency situations. The immediate and prompt institution of definitive measures such as surgery will in turn lead to lower mortality and morbidity. During the interview of junior doctors, we observed that they recognized abnormalities on brain CT scans mainly by looking for hyperdense lesions as well as asymmetry. Selections of images were based on
www.WORLDNEUROSURGERY.org
385
PEER-REVIEW REPORTS JI MIN LING ET AL.
USING MMS FOR SCAN IMAGE TRANSMISSION
Figure 2. Images chosen by the 15 doctors who were interviewed. The non-neurosurgically trained doctors are rows (from the top) 1, 3, 4, 5, 6, 8, 9, 10, 11, and 12. The neurosurgical residents are rows (from the top) 2, 7, 13, 14, and 15.
386
www.SCIENCEDIRECT.com
the widest diameter of the lesion or the greatest midline shift. The majority of the junior doctors were not confident in postulating the underlying pathologies (e.g., hemorrhage, tumor) and were also not conversant with providing a succinct verbal description of the lesion. This further substantiates our belief that the availability of MMS can significantly overcome this weak link of scan interpretation in the process of neurosurgical referral. Nevertheless, the use of MMS or any form of remote transmission of images does not obviate the need for formal clinical assessment and physical examination. MMS is not useful when the lesion is small, because the size and resolution of the image is greatly reduced on a mobile phone screen. Examples are small subarachnoid hemorrhage and early hydrocephalus, where only the temporal horns of the lateral ventricles are more prominent. Neurosurgeons therefore have to be aware of this pitfall when interpreting MMS images. Fundamentally, in any situation where scan findings do not correlate with clinical neurology, further assessment is mandatory. In our study, we identified two problems with MRIs of the spine. First, the fine details of MRIs could not be shown very well on a mobile phone screen. Second, interpretation of spinal MRI is a specialized skill. Only 3 of 10 non-neurosurgically trained doctors could read lumbar spine MRIs. The number of years of working experience does not correlate with the ability to read MRIs of the spine. Not surprisingly, the three doctors who could read MRIs of the lumbar spine had experience working in neurology and orthopedic surgery. The neurosurgeon on call normally decides, based on the specific clinical situation, if he or she needs to see the scan image after a phone consult. When required, he or she could ask the referring doctor to use a camera phone to capture a photograph of the image showing the lesion and then send the image via MMS. This process takes less than 5 minutes to complete. To safeguard patients’ confidentiality, we recommend sending images without tagging the identity of the patients in the MMS. The patient’s identity could be given to the neurosurgeon on call during the phone consult. Alternatively, it could be sent out in a different message/text following the MMS.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.03.023
PEER-REVIEW REPORTS JI MIN LING ET AL.
USING MMS FOR SCAN IMAGE TRANSMISSION
Table 1. Profile of the Junior Doctors Interviewed No.
Postinternship Year
Current Department
Previous Departments
1
1
Psychiatry
GM, GS, O&G (Internship)
2
1
General surgery
GM, GS, Ortho (Internship)
3
1
General surgery
GM, GS, Ortho (Internship)
4
1
General medicine
GM, GS, Ortho (Internship)
5
1
Gastroenterology
GM, GS (Internship)
6
2
Respiratory medicine
A&E, GM
7
2
Infectious disease
Cardiology, GM, infectious disease
8
3
General medicine
Neurology, cardiology, respiratory medicine, GM
9
4
Infectious disease
GM, geriatrics, respiratory medicine, anesthesia
10
5
Anesthesia
GM, GS, Peds, Ortho, A&E, anesthesia
GM, general medicine; GS, general surgery; O&G, obstetrics and gynecology; Ortho, orthopedic surgery; A&E, accident and emergency department; Peds, pediatrics.
CONCLUSION It is feasible and safe for junior doctors to utilize MMS to send brain CT images to the neurosurgeon on call while making an ur-
Table 2. Average Score of Neurosurgical Resident Versus NonNeurosurgically Trained Doctors Average (Excluding Average Spine) Neurosurgical resident
10/10
9/9
Non-neurosurgically trained doctor
9.2/10
8.9/9
gent referral. Junior doctors with no formal neurosurgical training are shown to be capable of identifying common lesions on brain CT scans encountered during neurosurgical emergencies. The images selected represented the pathology accurately and will be a useful adjunct in the neurosurgical referral process. Our study however showed a distinct deficiency in the interpretation of spine imaging, which deserves further study in the future.
2. Houkin K, Fukuhara S, Selladurai BM, Zurin AA, Ishak M, Kuroda S, Abe H: Telemedicine in neurosurgery using international digital telephone services between Japan and Malaysia: technical note. Neurol Med Chir (Tokyo) 39:773-778, 1999. 3. Kurasti H, Peponen J, Tervonen O, Kuutti K: The teleradiology system and changes in work practices. Comput Methods Programs Biomed 57:69-78, 1998. 4. Ng WH, Wang E, Bernstein M: Teleradiology and emergency neurosurgery—presence in a small Asian city state and need in a large Canadian province. J Brain Dis 1:7-11, 2009. 5. Ng WH, Wang E, Ng I: Multimedia messaging service teleradiology in the provision of emergency neurosurgery service. Surg Neurol 67:338-341, 2007. 6. Poon WS, Goh KY: The impact of teleradiology on the interhospital transfer of neurosurgical patients and their outcome. Hong Kong Med J 4:293-295, 1998. 7. Singh R, Ng WH, Lee KE, Wang E, Ng I, Lee WL: Telemedicine in emergency neurological service provision in Singapore: using technology to overcome limitation. Telemed J E Health 15:560-565, 2009. 8. Walters KA: Telephoned head injury referrals: the need to improve the quality of information provided. Arch Emerg Med 10:29-34, 1993.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. received 7 September, 2010; accepted 22 March 2011 Citation: World Neurosurg. (2012) 77, 2:384-387. DOI: 10.1016/j.wneu.2011.03.023
REFERENCES 1. Goh KY, Lam CK, Poon WS: The impact of teleradiology on the interhospital transfer of neurosurgical patients. Br J Neurosurg 11:52-56, 1997.
WORLD NEUROSURGERY 77 [2]: 384-387, FEBRUARY 2012
Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
387