Telesonography: foundations and future directions

Accuracy and reliability of tele-ultrasonography in detecting gastrointestinal obstruction in dogs and cats

OBJECTIVES

To assess the accuracy and interobserver agreement of tele-ultrasonography for the diagnosis of gastrointestinal obstruction in small animals by radiologists with different levels of experience.

MATERIALS AND METHODS

A retrospective cross-sectional study including dogs and cats admitted with gastrointestinal signs, between 2017 and 2019, that had abdominal ultrasonographic (US) examination performed and images saved for review. Patients were classified into two categories based on final diagnosis: animals with or without complete or partial gastrointestinal obstruction. Observers with four experience levels interpreted the archived ultrasound examinations, simulating a tele-ultrasonography consultation. Analyses of accuracy, sensitivity, specificity, positive and negative predictive values were obtained for each observer for detection of gastrointestinal obstruction. Agreement between observers for the gastrointestinal obstruction diagnosis was assessed using Fleiss's Kappa statistics.

RESULTS

Ninety patients with gastrointestinal signs were included. Of these, 23 of 90 had partial or complete gastrointestinal obstruction. Interpretation of the images by observers via tele-ultrasonography showed intervals of accuracy, sensitivity, specificity, positive and negative predictive values, respectively, of 78.9% to 87.8%, 73.9% to 100%, 77.6% to 89.6%, 55.9% to 70.8% and 90.9% to 100% for diagnosis of gastrointestinal obstruction. Agreement for the gastrointestinal obstruction diagnosis across all reviewers was moderate (Kappa 0.6).

CLINICAL SIGNIFICANCE

Tele-ultrasonography had good accuracy for detection of gastrointestinal obstruction, however had a rather low positive predictive value and only moderate interobserver agreement. Therefore, this technique should be used with caution in this clinical context, given the potential surgical decision at hand.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Improving the quality of breast ultrasound examination performed by inexperienced ultrasound doctors with synchronous tele-ultrasound: a prospective, parallel controlled trial

PURPOSE

This prospective study explored the value of synchronous tele-ultrasound (US) to aid doctors inexperienced in US with breast US examinations.

METHODS

In total, 99 patients were enrolled. Two trainee doctors who were inexperienced in US (trainee A [TA] and trainee B [TB]) and one doctor who was an expert in US completed the US examinations sequentially. TA completed the US examinations independently, while TB was instructed by the expert using synchronous tele-US. Subsequently, the expert performed on-site US examinations in person. Separately, they selected the most clinically significant nodule as the target nodule. Consistency with the expert and image quality were compared between TA and TB to evaluate tele-US. Furthermore, TB and the patients evaluated tele-US through questionnaires.

RESULTS

TB demonstrated higher consistency with the expert in terms of target nodule selection than TA (93.3% vs. 63.3%, P<0.001). TB achieved good inter-observer agreement (>0.75) with the expert on five US features (5/9, 55.6%), while TA only did so for one (1/9, 11.1%) (P=0.046). TB's image quality was higher than TA's in gray value, time gain compensation, depth, color Doppler adjustment, and the visibility of key information (P=0.018, P<0.001, P<0.001, P=0.033, and P=0.006, respectively). The comprehensive assessment score was higher for TB than for TA (3.96±0.82 vs. 3.09±0.87, P<0.001). Tele-US was helpful in 69.7% of US examinations and had a training effect in 68.0%. Furthermore, 63.6% of patients accepted tele-US and 60.6% were willing to pay.

CONCLUSION

Tele-US can help doctors inexperienced in US to perform breast US examinations.

Implementation of a fetal ultrasound telemedicine service: women's views and family costs

Background

The complexity of fetal medicine (FM) referrals that can be managed within obstetric units is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service linking a specialist fetal medicine (FM) centre and a remote obstetric unit.

Methods

Over a four-year period from October 2015, all women referred for FM consultation from the obstetric unit were seen via telemedicine, excluding cases where invasive testing, intrauterine therapy or cardiac anomalies were anticipated. The outcomes measured included the indication for FM referral; scan duration and image and sound quality during the consultation. Women’s perceptions of the telemedicine consultation and estimated costs to attend the FM centre were measured by a structured questionnaire completed following the first telemedicine appointment during the Phase 1 of the project.

Results

Overall, 297 women had a telemedicine consultation during Phase 1 (pilot and evaluation) and Phase 2 (embedding and adoption) of the project, which covered a 4 year period 34 women completed questionnaires during the Phase 1 of the study. Travel to the telemedicine consultation took a median (range) time of 20 min (4150), in comparison to an estimated journey of 230 min (120,450) to the FM centre. On average, women would have spent approximately £28 to travel to the FM centre per visit. The overall costs for the woman and her partner/ friend to attend the FM centre was estimated to be £439.

Women were generally satisfied with the service and valued the opportunity to have a FM consultation locally.

Conclusions

We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced to provide FM ultrasound of sufficient quality to allow fetal diagnosis and specialist consultation with parents. Furthermore, the service is acceptable to parents, has shown a reduction in family costs and journey times.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03532-4.

National electrocardiographic mapping by telemedicine for diagnosis and prevention of cardiological pathologies in Paraguay

Introduction:

Telemedicine tools offer multiple advantages to achieve an epidemiological screening of communities in rural settings countrywide. However, evidence on the cardiological pathology surveillance in these communities is limited. The feasibility of telemedicine as an electrocardiographic (EKG) mapping tool for the diagnosis and prevention of cardiological pathologies in Paraguay was investigated.

Methods:

A descriptive study was conducted in 60 telediagnostic centers countrywide in Paraguay to evaluate the feasibility of telemedicine as an EKG mapping tool for the diagnosis and prevention of cardiological pathologies over a period of 5 years from 2014 to 2018. The adherence rate was determined comparing yearly scheduled visits versus fulfilled visits at the telemedicine platform.

Results:

During the study, 246,217 remote EKG diagnoses were performed in 60 hospitals using telemedicine. The patients were 19.4% children/adolescents and 80.6% adults. The results of EKG tests in the children/adolescent group were 79.4% normal and 20.6% abnormal. The most frequent abnormal heart rhythms observed were sinusal bradicardia (10.6%), sinusal tachycardia (3.2%), and unspecified arrhythmia (2.8%). In the adult group, the results were 66.3% normal and 33.7% abnormal. The most frequent abnormal heart rhythms in this group were sinusal bradicardia (11.2%), blockade of the right branch (4.8%), and left ventricular hypertrophy (4.7%). The most frequent cardiovascular risk factors observed were the association of hypertension and obesity (40%), hypertension and diabetes (20%), and hypertension and dyslipidemia (19%). During the test period (2014–2018), the average rate of patient adherence to the prevention program was 2.26 for each 1000 diagnosis.

Conclusion:

These results demonstrate the feasibility of telemedicine as an EKG mapping tool for the diagnosis and prevention of cardiological pathologies in low-resource countries, thus enhancing cardiovascular disease surveillance and optimizing human and financial resources.

Telesonography in emergency medicine: A systematic review

Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.

Deep learning for cardiac computer-aided diagnosis: benefits, issues & solutions

Cardiovascular diseases are one of the top causes of deaths worldwide. In developing nations and rural areas, difficulties with diagnosis and treatment are made worse due to the deficiency of healthcare facilities. A viable solution to this issue is telemedicine, which involves delivering health care and sharing medical knowledge at a distance. Additionally, mHealth, the utilization of mobile devices for medical care, has also proven to be a feasible choice. The integration of telemedicine, mHealth and computer-aided diagnosis systems with the fields of machine and deep learning has enabled the creation of effective services that are adaptable to a multitude of scenarios. The objective of this review is to provide an overview of heart disease diagnosis and management, especially within the context of rural healthcare, as well as discuss the benefits, issues and solutions of implementing deep learning algorithms to improve the efficacy of relevant medical applications.

[Public health impact of a remote diagnosis system implemented in regional and district hospitals in Paraguay]

Objetivo.

Determinar la viabilidad y puesta en marcha de un sistema de telediagnóstico para dar asistencia sanitaria a poblaciones remotas y dispersas del Paraguay.

Métodos.

El estudio fue realizado en todos los hospitales regionales, generales y principales hospitales distritales de las 18 regiones sanitarias del Paraguay. En el sistema se registraron los datos clínicos y las imágenes tomográficas, ecográficas y trazados electrocardiográficos del paciente que precisaba de un diagnóstico por parte de un médico especialista. Esta información se transmitió a los especialistas en imagenología y en cardiología para su diagnóstico remoto y posterior envío del informe a los hospitales conectados al sistema. Se analizó el costo-beneficio e impacto de la herramienta de telediagnóstico desde la perspectiva del Sistema Nacional de Salud.

Resultados.

Entre enero de 2014 y mayo de 2015 se realizaron 34 096 telediagnósticos distribuidos en 25 hospitales a través del Sistema de Telemedicina del Ministerio de Salud. El costo unitario promedio del diagnóstico remoto fue de USD 2,6 (dólares estadounidenses) para electrocardiograma (ECG), tomografía y ecografía, mientras que el costo unitario para el diagnóstico “cara a cara” fue de UDS 11,8 para ECG; USD 68,6 para tomografía y USD 21,5 para ecografía. La reducción del costo mediante el diagnóstico remoto fue de 4,5 veces para ECG; 26,4 veces para tomografía y de 8,3 veces para ecografía. En términos monetarios, la implementación del sistema de telediagnóstico, durante los 16 meses del estudio, significó un ahorro promedio de USD 2 420 037.

Conclusión.

Paraguay cuenta con un sistema de telediagnóstico para electrocardiografía, tomografía y ecografía aplicando las tecnologías de la información y comunicación (TIC) de bajo costo, basadas en software libre y escalable a otros tipos de estudios diagnósticos a distancia; de interés para la salud pública. Con una aplicación práctica del telediagnóstico, se contribuyó al fortalecimiento de la red integrada de servicios y programas de salud, lo que permitió maximizar el tiempo del profesional y su productividad, mejorar la calidad, aumentar el acceso y la equidad, y disminuir los costos.

Teleultrasound: historical perspective and clinical application

The health care of patients in rural or isolated areas is challenged by the scarcity of local resources, limited patient access to doctors and hospitals, and the lack of specialized professionals. This has led to a new concept in telemedicine: teleultrasonography (or teleultrasound), which permits ultrasonographic diagnoses to be performed remotely. Telemedicine and teleultrasonography are effective in providing diagnostic imaging services to these populations and reduce health care costs by decreasing the number and duration of hospitalizations and reducing unnecessary surgical procedures. This is a narrative review to present the potential clinical applications of teleultrasonography in clinical practice. The results indicate that although barriers persist for implementing teleultrasonography in a more universal and routine way, advances in telecommunications, Internet bandwidth, and the high resolution currently available for portable ultrasonography suggest teleultrasonography applications will continue to expand. Teleultrasound appears to be a valuable addition to remote medical care for isolated populations with limited access to tertiary healthcare facilities and also a useful tool for education and training.