The major goals of telemedicine today are to develop next-generation telehealth tools and technologies to enhance healthcare delivery to medically underserved populations using telecommunication technology, to increase access to medical specialty services while decreasing healthcare costs, and to provide training of healthcare providers, clinical trainees, and students in health-related fields. Key drivers for these tools and technologies are the need and interest to collaborate among telehealth stakeholders, including patients, patient communities, research funders, researchers, healthcare services providers, professional societies, industry, healthcare management= economists, and healthcare policy makers. In the development, marketing, adoption, and implementation of these tools and technologies, communication, training, cultural sensitivity, and end-user customization are critical pieces to the process. Next-generation tools and technologies are vehicles toward personalized medicine, extending the telemedicine model to include cell phones and Internet-based telecommunications tools for remote and home health management with video assessment, remote bedside monitoring, and patient-specific care tools with event logs, patient electronic profile, and physician note-writing capability. Telehealth is ultimately a system of systems in scale and complexity. To cover the full spectrum of dynamic and evolving needs of end-users, we must appreciate system complexity as telehealth moves toward increasing functionality, integration, interoperability, outreach, and quality of service. Toward that end, our group addressed three overarching questions: (1) What are the highimpact topics? (2) What are the barriers to progress? and (3) What roles can the National Institutes of Health and its various institutes and centers play in fostering the future development of telehealth?

Otolaryngology has seen a rapid proliferation of functional endoscopic sinus surgery, and there is variability in the teaching of the procedure, in part because of the seriousness of the complications. A retrospective review of 106 consecutive cases was conducted at a teaching program to evaluate complications. Complication rates were combined and compared with the reported complication rates of other teaching programs and practicing otolaryngologists. The complication rate in our program was 13.9%; all were minor complications. This compared favorably with the rates of other programs (6% to 29%). The combined complication rate for residency training programs (16.6%) was significantly greater than the nonresident complication rate (10.5%). When divided into major and minor complications, the resident minor complication rate (15.9%) was significantly greater than the nonresident rate (8%), yet the major complication rates were significantly less for the resident group (0.7%) than for the nonresident group (2.5%). In addition, complications were significantly greater when procedures were performed under general anesthesia as compared with local anesthesia, and estimated blood loss was significantly greater under general anesthesia.

Objectives: Virtual reality (VR) environments offer potential advantages over traditional paper methods, manikin simulation, and live drills for mass casualty training and assessment. The authors measured the acquisition of triage skills by novice learners after exposing them to three sequential scenarios (A, B, and C) of five simulated patients each in a fully immersed three-dimensional VR environment. The hypothesis was that learners would improve in speed, accuracy, and self-efficacy.Methods: Twenty-four medical students were taught principles of mass casualty triage using three short podcasts, followed by an immersive VR exercise in which learners donned a head-mounted display (HMD) and three motion tracking sensors, one for their head and one for each hand. They used a gesture-based command system to interact with multiple VR casualties. For triage score, one point was awarded for each correctly identified main problem, required intervention, and triage category. For intervention score, one point was awarded for each correct VR intervention. Scores were analyzed using one-way analysis of variance (ANOVA) for each student. Before and after surveys were used to measure self-efficacy and reaction to the training.Results: Four students were excluded from analysis due to participation in a recent triage research program. Results from 20 students were analyzed. Triage scores and intervention scores improved significantly during Scenario B (p < 0.001). Time to complete each scenario decreased significantly from A (8:10 minutes) to B (5:14 minutes; p < 0.001) and from B to C (3:58 minutes; p < 0.001). Self-efficacy improved significantly in the areas of prioritizing treatment, prioritizing resources, identifying high-risk patients, and beliefs about learning to be an effective first responder.Conclusions: Novice learners demonstrated improved triage and intervention scores, speed, and selfefficacy during an iterative, fully immersed VR triage experience.

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These efforts performed in a stepwise approach will lead to an otolaryngology--head and neck surgery service that is on-line for the next millennium, with telemedicine advances normalized to the standard of care.

Ketorolac tromethamine (KT) is a nonsteroidal, antiinflammatory analgesic. Its nonsedating property makes it an attractive analgesic for sleep apnea patients undergoing uvulopharyngopalatoplasty, but its antiplatelet activity makes the potential for postoperative hemorrhage a concern. A prospective, randomized, double-blind study was designed to evaluate the bleeding risk of KT using adult tonsillectomy patients as the model. Patients were randomized into two groups receiving Meperidine (MP) (controls) or KT for the first postoperative day. Posttonsillectomy bleeding rates of 7% (3/43) in the MP group and 18.9% (7/37) in the KT group were demonstrated, but this difference was not statistically significant. The number of KT doses administered had no effect on the incidence of bleeding or the number of cases requiring return to the operative suite for hemostasis. Although this study did not attain statistical significance, the trend towards increased hemorrhage with KT is worrisome. This study and other reports in the literature support the manufacturer's warning that the use of KT is contraindicated in major surgery.

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A study was conducted to better define the relationship between closing tension and the resulting scar width of incisional wounds. Five groups of 10 hairless rats each were studied. Transverse wounds were created and closed on the back of each rat, with closing tension varied by excising amounts of skin in widths of 0 (control), 15, 30, 45, and 60 mm. At 28 days, the scar width was measured by three methods: digital caliper, photographically, and histologically. Results showed that wounds closed under the highest tension (60-mm excision group) had significantly wider scars than controls by all three measurement techniques. Regression analysis of the caliper scar width as determined by squaring the closing tension resulted in a nonlinear equation resembling an exponential curve that "best fit" the variables.