***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services . We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital . All patients requiring emergency neurosurgical consultation were included for r and omization into  telephone consultation only  ( Mode A ) ,  teleradiology and telephone consultation ( Mode B ) and video-consultation ( Mode C ) . Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score . In a 10-month period , 327 patients were recruited and r and omized into the study : the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 ( 38 % ) . There was a trend towards a more favourable outcome in the video-consultation mode ( 44 % , Mode C ) , versus teleradiology ( 31 % , Mode B ) , versus telephone consultation ( 38 % , Mode A ) . The interim data of this prospect i ve r and omized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations Background  Inter-hospital teleconsultation  improves stroke care . To transfer this concept into the emergency medical service ( EMS ) , the feasibility and effects of prehospital teleconsultation were investigated . Methodology /Principal Findings Teleconsultation enabling audio communication , real-time video streaming , vital data and still picture transmission was conducted between an ambulance and a teleconsultation center . Pre-notification of the hospital was carried out with a 14-item stroke history checklist via e-mail-to-fax . Beside technical assessment s possible influences on prehospital and initial in-hospital time intervals , prehospital diagnostic accuracy and the transfer of stroke specific data were investigated by comparing telemedically assisted prehospital care ( telemedicine group ) with local regular EMS care ( control group ) .  All prehospital stroke patients over a 5-month period were included during weekdays ( 7.30 a.m. –4.00 p.m. ) . In 3 of 18 missions partial dropouts of the system occurred ; neurological co-evaluation via video transmission was conducted in 12 cases . The stroke checklist was transmitted in 14 cases ( 78 % ) . Telemedicine group ( n = 18 ) vs. control group ( n = 47 ) : Prehospital time intervals were comparable , but in both groups the door to brain imaging times were longer than recommended ( median 59.5 vs. 57.5 min , p = 0.6447 ) . The prehospital stroke diagnosis was confirmed in 61 % vs. 67 % , p = 0.8451 . Medians of 14 ( IQR 9 ) vs. 5 ( IQR 2 ) stroke specific items were transferred in written form to the in-hospital setting , p<0.0001 . In 3 of 10 vs. 5 of 27 patients with cerebral ischemia thrombolytics were administered , p = 0.655 . Conclusions Teleconsultation was feasible but technical performance and reliability have to be improved . The approach led to better stroke specific information ; however , a superiority over regular EMS care was not found and in-hospital time intervals were unacceptably long in both groups . The feasibility of prehospital tele-stroke consultation has future potential to improve emergency care especially when no highly trained personnel are on-scene . Trial Registration International St and ard R and omised Controlled Trial Number Register ( IS RCT N ) IS RCT N83270177 83270177 OBJECTIVE To evaluate the reliability of strabismus assessment using telemedicine ( TM ) technology . DESIGN Two prospect i ve interobserver agreement studies . One study compared the agreement between a st and ard and a TM examination , whereas the other assessed agreement between two independent st and ard examinations . PARTICIPANTS Strabismus patients over 4 years of age examined at a remote community clinic and patients assessed in a strabismologist 's urban practice . METHODS Forty-two patients were examined in person by a pediatric ophthalmologist at the remote community and independently by a pediatric ophthalmology fellow by means of TM ( TM-st and ard study ) . The TM examination was performed with the help of a qualified ophthalmic assistant at the remote telecommunication center using a Power Cam 100 camera , a Picture Tel Concorde 4500 teleconferencing system , and a 224 kilobyte b and width . For comparison , independent in person examinations were performed on 43 patients by both examiners ( st and ard-st and ard study ) . Agreement was measured using unweighted kappa ( k ) for categorical data , the intraclass correlation coefficient ( ICC ) for continuous data , and percent agreement . The odds of disagreement with TM  ( comparing the TM-st and ard versus st and ard-st and ard studies ) was assessed with logistic regression analysis . MAIN OUTCOME MEASURES Three parameters were assessed : ( 1 ) category of strabismus , determined by observation without cover test ; ( 2 ) angle of deviation at 0.33 and 6.0 m ; and ( 3 ) ocular muscle action . RESULTS Agreement on the category of strabismus was good ( k > 0.61 ) other than for vertical deviations . However , there was good to excellent agreement between TM and st and ard examinations on the vertical ( ICC = 0.78 ) and horizontal ( ICC = 0.79 ) angles of deviation with 6-m fixation with the cover test . Muscle ratings agreed within one point for the lateral , superior , and inferior rectus muscle actions in more than 90 % of the eyes examined . Although good agreement was observed in the TM-st and ard study , it was inferior to the agreement in the st and ard-st and ard study . Examination by TM increased the odds of disagreement compared with examination in person by twofold to threefold . CONCLUSIONS Strabismus examination can be performed with a good level of reliability with the use of medium b and width video teleconferencing equipment . However , reduced reliability has been noted in the detection of  small vertical deviations by inspection and in evaluating oblique muscle actions OBJECTIVE To prospect ively measure accuracy , reliability , and image quality of telemedical retinopathy of prematurity ( ROP ) diagnosis . METHODS Two-hundred forty-eight eyes from 67 consecutive infants underwent wide-angle retinal imaging by a trained neonatal nurse at 31 to 33 weeks ' and /or 35 to 37 weeks ' postmenstrual age ( PMA ) using a st and ard protocol . Data were uploaded to a Web-based telemedicine system and interpreted by 3 expert retinal specialist grade rs who provided a diagnosis ( no ROP , mild ROP , type 2 prethreshold ROP , treatment-requiring ROP ) and an evaluation of image quality for each eye . Findings were compared with a reference st and ard of indirect ophthalmoscopy by an experienced pediatric ophthalmologist . RESULTS At 35 to 37 weeks ' PMA , sensitivity and specificity for diagnosis of mild or worse ROP were 0.908 and 1.000 for grade r A , 0.971 and 1.000 for grade r B , and 0.908 and 0.977 for grade r C. Sensitivity and specificity for diagnosis of type 2 prethreshold or worse ROP were 1.000 and 0.943 for grade r A , 1.000 and 0.930 for grade r B , and 1.000 and 0.851 for grade r C. At 35 to 37 weeks ' PMA , weighted kappa for inter grade r reliability was 0.791 to 0.889 , and kappa for intra grade r reliability for detection of type 2 prethreshold or worse ROP was 0.769 to 1.000 . Image technical quality was rated as " adequate " or " possibly adequate " for diagnosis in 93.3 % to 100 % of eyes . CONCLUSION A telemedicine system using nurse-captured retinal images has the potential to improve existing shortcomings of ROP management , particularly at later PMAs Objective : Evaluate whether telemedicine can be used to perform dysmorphology and neurologic examinations in the neonatal intensive care unit ( NICU ) by determining the examination accuracy , limitations and optimized procedures . Study Design : Prospect i ve evaluation of NICU patients referred for subspecialty consultation for dysmorphic features ( n=10 ) or encephalopathy ( n=10 ) . A physician at bedside ( bedside clinician ) performed an in-person examination that was viewed in real time by a remote physician ( remote consultant ) . St and ardized examinations were recorded and compared . Subsequently , a qualitative approach established technique adjustments and optimization procedures necessary to improve visualization . Result : Telemedicine examinations identified 81 of 87 ( 93 % ) dysmorphology examination abnormalities and 37 of 39 ( 92 % ) neurologic examination abnormalities . Optimization of remote consultant visualization required an active bedside clinician assisting in camera and patient adjustments . Conclusion : Telemedicine can be used to perform accurately many components of the dysmorphology or neurologic examinations in NICU patients , but physicians must be mindful of specific limitations Introduction . Diabetic retinopathy ( DR ) is the leading cause of preventable blindness in Australia . Up to 50 % of people with proliferative DR who do not receive timely treatment will become legally blind within five years . Innovative and accessible screening , involving a variety of primary care providers , will become increasingly important if patients with diabetes are to receive optimal eye care . Method . An open controlled trial design was used . Five intervention practice s in urban , regional , and rural Australia partnered with ophthalmologists via telehealth undertook DR screening and monitoring of type 2 diabetes patients  and were compared with  control practice s undertaking usual care 2011–2014 . Results . Recorded screening rates were 100 % across intervention practice s , compared with 22–53 % in control practice s. 31/577 ( 5 % ) of patients in the control practice s were diagnosed with mild-moderate DR , of whom 9 ( 29 % ) had appropriate follow-up recorded . This was compared with 39/447 ( 9 % ) of patients in the intervention group , of whom 37 ( 95 % ) had appropriate follow-up recorded . Discussion and Conclusion . General practice -based DR screening via Annual Cycle of Care arrangements is effective across differing practice locations . It offers improved recording of screening outcomes for Australians with type 2 diabetes and better follow-up of those with screen abnormalities Background / aims Digital retinal imaging using store- and -forward technology is used to screen for diabetic retinopathy ( DR ) . Its usefulness in detecting non-diabetic eye diseases is uncertain . We determined the level of agreement between teleretinal imaging supplemented with visual acuity and intraocular pressure ( IOP ) measurements  ( ie , technology-assisted eye ( TAE ) exam ) and a comprehensive eye exam in evaluation for DR and non-diabetic ocular conditions . Methods We conducted a prospect i ve , observational study with two parallel evaluations . Patients with diabetes ( n=317 ) had a TAE exam  and a comprehensive eye exam on the same day . A subset of participants with normal baseline exams ( n=72 ) had follow-up exams 1 year later . We measured the level of agreement for referable ocular findings . Results Agreement for referable ocular findings was moderate ( n=389 , agreement : 77 % ; κ : 0.55 ) , due in part to ungradable exams ( 22 % ) . However , about half of the ungradable exams had findings that warranted referral . There was substantial agreement for follow-up exams ( n=72 , agreement : 93 % ; κ : 0.63 ) . Among all gradable exams ( n=303 ) , the TAE exam had 86 % sensitivity and 84 % specificity for referable ocular findings , with high agreement ( ≥94 % ) for DR and other major ocular diagnoses . Conclusions There was moderate-to-substantial agreement between a TAE exam and a comprehensive eye exam for referable ocular findings in patients with diabetes . Ungradable exams were a frequent marker of ocular pathology . Teleretinal imaging may be a useful evaluation for both diabetic and non-diabetic ocular conditions OBJECTIVE To report a pilot study of telemedical direct ophthalmoscopy in the diagnosis of acquired immune deficiency syndrome (AIDS)-related retinopathy in a human immunodeficiency virus (HIV)-positive population and in the diagnosis of glaucoma , cataract , and retinopathy in a diabetic population . DESIGN Prospect i ve comparative case series . PARTICIPANTS Seventeen HIV-positive and 20 diabetic patients . METHODS A direct ophthalmoscope custom-fitted with a digital microcamera capable of transmitting images from any of 61 sites within the Georgia Statewide  Telemedicine Program was used by a nonophthalmologist to examine 34 eyes of 17 HIV-positive patients and 39 eyes of 20 patients with diabetes . Fundus images were transmitted in real-time to a review ing ophthalmologist . An in-person , comprehensive examination including indirect ophthalmoscopy , was performed by a second ophthalmologist . Telemedical examination was compared to the in-person comprehensive examination . RESULTS For the HIV 
    Output:
    
Store- and -forward image transmission coupled with real-time videoconferencing is a suitable alternative to overcome poor internet transmission speeds