Preliminary experience with tele-sonography and tele-mammography in Togo

Tele-Ultrasound in Resource-Limited Settings: A Systematic Review

Background: Telemedicine, or healthcare delivery from a distance, has evolved over the past 50 years and helped alter health care delivery to patients around the globe. Its integration into numerous domains has permitted high quality care that transcends obstacles of geographic distance, lack of access to health care providers, and cost. Ultrasound is an effective diagnostic tool and its application within telemedicine (“tele-ultrasound”) has advanced substantially in recent years, particularly in high-income settings. However, the utility of tele-ultrasound in resource-limited settings is less firmly established.

Objective: To determine whether remote tele-ultrasound is a feasible, accurate, and care-altering imaging tool in resource-limited settings.

Data Sources: PubMed, MEDLINE, and Embase.

Study Eligibility Criteria: Twelve original articles met the following eligibility criteria: full manuscript available, written in English, including a direct patient-care intervention, performed in a resource-limited setting, images sent to a remote expert reader for interpretation and feedback, contained objective data on the impact of tele-ultrasound.

Study Appraisal and Synthesis Methods: Abstracts were independently screened by two authors against inclusion criteria for full-text review. Any discrepancies were settled by a senior author. Data was extracted from each study using a modified Cochrane Consumers and Communication Review Group's data extraction template. Study bias was evaluated using the ROBINS-I tool.

Results: The study results reflect the diverse applications of tele-ultrasound in low-resource settings. Africa was the most common study location. The specialties of cardiology and obstetrics comprised most studies. Two studies primarily relied on smartphones for image recording and transmission. Real-time, rather than asynchronous, tele-ultrasound image interpretation occurred in five of the 12 studies. The most common outcome measures were image quality, telemedicine system requirements, diagnostic accuracy, and changes in clinical management.

Limitations: The studies included were of poor quality with a dearth of randomized control trials and with significant between study heterogeneity which resulted in incomplete data and made cross study comparison difficult.

Conclusions and Implications of Key Findings: Low-quality evidence suggests that ultrasound images acquired in resource-limited settings and transmitted using a telemedical platform to an expert interpreter are of satisfactory quality and value for clinical diagnosis and management.

Assessing the Coverage of E-Health Services in Sub-Saharan Africa. A Systematic Review and Analysis

BACKGROUND

E-Health has attracted growing interests globally. The relative lack of facilities, skills, funds and information on existing e-Health initiatives has affected progress on e-Health in Africa.

OBJECTIVES

To review publicly available literature on e-Health in sub-Saharan Africa (sSA) towards providing information on existing and ongoing e-Health initiatives in the region.

METHODS

Searches of relevant literature were conducted on Medline, EMBASE and Global Health, with search dates set from 1990 to 2016. We included studies on e-Health initiatives (prototypes, designs, or completed projects) targeting population groups in sSA.

RESULTS

Our search returned 2322 hits, with 26 studies retained. Included studies were conducted in 14 countries across the four sub-regions in sSA (Central, East, South and West) and spreading over a 12-year period, 2002-2014. Six types of e-Health interventions were reported, with 17 studies (65 %) based on telemedicine, followed by mHealth with 5 studies (19 %). Other e-Health types include expert system, electronic medical records, e-mails, and online health module. Specific medical specialties covered include dermatology (19 %), pathology (12 %) and radiology (8 %). Successes were 'widely reported' (representing 50 % overall acceptance or positive feedbacks in a study) in 10 studies (38 %). The prominent challenges reported were technical problems, poor internet and connectivity, participants' selection biases, contextual issues, and lack of funds.

CONCLUSION

E-Health is evolving in sSA, but with poorly published evidence. While we call for more quality research in the region, it is also important that population-wide policies and on-going e-Health initiatives are contextually feasible, acceptable, and sustainable.

Real-Time Tele-Mentored Low Cost "Point-of-Care US" in the Hands of Paediatricians in the Emergency Department: Diagnostic Accuracy Compared to Expert Radiologists

BACKGROUND

The use of point-of-care ultrasonography (POC US) in paediatrics is increasing. This study investigated the diagnostic accuracy of POC US in children accessing the emergency department (ED) when performed by paediatricians under the remote guidance of radiologists (TELE POC).

METHODS

Children aged 0 to 18 years accessing the ED of a third level research hospital with eight possible clinical scenarios and without emergency/severity signs at the triage underwent three subsequent US tests: by a paediatrician guided remotely by a radiologist (TELE POC); by the same radiologist (UNBLIND RAD); by an independent blinded radiologist (BLIND RAD). Tele-radiology was implemented using low cost "commercial off-the-shelf" (COTS) equipment and open-source software. Data were prospectively collected on predefined templates.

RESULTS

Fifty-two children were enrolled, for a total of 170 ultrasound findings. Sensitivity, specificity, positive and negative predictive values of TELE POC were: 93.8, 99.7, 96.8, 99.4 when compared to UNBLIND RAD and 88.2, 99.7, 96.8, 98.7 when compared to BLIND RAD. The inter-observers agreement between the paediatricians and either the unblind or blind radiologist was excellent (k = 0.93). The mean duration of TELE POC was 6.3 minutes (95% CI 4.1 to 8.5). Technical difficulties occurred in two (3.8%) cases. Quality of the transmission was rated as fair, good, very good and excellent in 7.7%, 15.4%, 42.3% and 34.6% of cases respectively, while in no case was it rated as poor.

CONCLUSIONS

POC US performed by paediatricians in ED guided via tele-radiology by an expert radiologist (TELE POC) produced reliable and timely diagnoses. Findings of this study, especially for the rarer conditions under evaluation, need further confirmation. Future research should investigate the overall benefits and the cost savings of using tele-ultrasound to perform US "at children's bedsides", under remote guidance of expert radiologists.

A national teleradiology programme in Mali: implementation and results

We reviewed the national teleradiology programme in Mali to establish whether it improved diagnosis for patients and improved the referring doctor's ability to give an accurate diagnosis. The teleradiology programme connected the University Hospital in Bamako to all seven regional hospitals in Mali and one private health clinic. The pilot phase began in 2005 in three hospitals. Initially the implementation involved connections via broadband, but subsequently satellite antennae were provided at three remote hospitals in the north. Between 2005 and 2013, X-ray and mammogram images from 5628 patients were read by teleradiology. Radiologists provided the sole diagnosis for 29% of cases (i.e. the referrer did not make a diagnosis) and altered the regional doctor's diagnosis in 12% of cases. The proportion of cases for which the regional doctor gave no diagnosis decreased from 93% to 24% over the same period, indicating an increase in the doctors' confidence and incentive to test their own diagnosis. The percentage of cases for which regional doctors made an inaccurate diagnosis decreased to 3% in 2013. Use of the teleradiology service varied widely between hospitals. Successful implementation depended on local ownership of a network, which was developed in close collaboration with hospital leadership, national radiologists and other healthcare personnel.

A low-cost tele-imaging platform for developing countries

PURPOSE

To design a "low-cost" tele-imaging method allowing real-time tele-ultrasound expertise, delayed tele-ultrasound diagnosis, and tele-radiology between remote peripherals hospitals and clinics (patient centers) and university hospital centers (expert center).

MATERIALS AND METHODS

A system of communication via internet (IP camera and remote access software) enabling transfer of ultrasound videos and images between two centers allows a real-time tele-radiology expertise in the presence of a junior sonographer or radiologist at the patient center. In the absence of a sonographer or radiologist at the patient center, a 3D reconstruction program allows a delayed tele-ultrasound diagnosis with images acquired by a lay operator (e.g., midwife, nurse, technician). The system was tested both with high and low bandwidth. The system can further accommodate non-ultrasound tele-radiology (conventional radiography, mammography, and computer tomography for example). The system was tested on 50 patients between CHR Tsevie in Togo (40 km from Lomé-Togo and 4500 km from Tours-France) and CHU Campus at Lomé and CHU Trousseau in Tours.

RESULTS

A real-time tele-expertise was successfully performed with a delay of approximately 1.5 s with an internet bandwidth of around 1 Mbps (IP Camera) and 512 kbps (remote access software). A delayed tele-ultrasound diagnosis was also performed with satisfactory results. The transmission of radiological images from the patient center to the expert center was of adequate quality. Delayed tele-ultrasound and tele-radiology was possible even in the presence of a low-bandwidth internet connection.

CONCLUSION

This tele-imaging method, requiring nothing by readily available and inexpensive technology and equipment, offers a major opportunity for telemedicine in developing countries.