Teleoperated Echograph and Probe Transducer for Remote Ultrasound Investigation on Isolated Patients (Study of 100 Cases)

A 5G-based telerobotic ultrasound system provides qualified abdominal ultrasound services for patients on a rural island: a prospective and comparative study of 401 patients

PURPOSE

To explore the feasibility of a 5G-based telerobotic ultrasound (US) system for providing qualified abdominal US services on a rural island.

METHODS

This prospective study involved two medical centers (the tele-radiologist site's hospital and the patient site's hospital) separated by 72 km. Patients underwent 5G-based telerobotic US by tele-radiologists and conventional US by on-site radiologists from September 2020 to March 2021. The clinical feasibility and diagnostic performance of the 5G-based telerobotic abdominal US examination were assessed based on safety, duration, image quality, diagnostic findings, and questionnaires.

RESULTS

A total of 401 patients (217 women and 184 men; mean age, 54.96 ± 15.43 years) were enrolled. A total of 90.1% of patients indicated no discomfort with the telerobotic US examination. For the examination duration, telerobotic US took longer than conventional US (12.54 ± 3.20 min vs. 7.23 ± 2.10 min, p = 0.001). For image quality scores, the results of the two methods were similar (4.54 ± 0.63 vs. 4.57 ± 0.61, p = 0.112). No significant differences were found between the two methods in measurements for the aorta, portal vein, gallbladder, kidney (longitudinal diameter), prostate, and uterus; however, telerobotic US underestimated the transverse diameter of the kidney (p < 0.05). A total of 504 positive results, including 31 different diseases, were detected. Among them, 455 cases were identified by the two methods; 17 cases were identified by telerobotic US only; and 32 cases were identified by conventional US only. There was good consistency in the diagnosis of 29 types of disease between the two methods (κ = 0.773-1.000). Furthermore, more than 90% of patients accepted the telerobotic US examination and agreed to pay additional fees in future.

CONCLUSION

The 5G-based telerobotic US system can expand access to abdominal US services for patients in rural areas, thereby reducing health care disparities.

Current Applications of Robot-Assisted Ultrasound Examination

Despite advances in miniaturization and automation, the need for expert acquisition of a full echocardiogram, including Doppler, has restricted access in remote areas. Recent developments in robotics, teleoperation, and upgraded telecommunications infrastructure may provide a solution to this deficiency. Robot-assisted teleoperated ultrasound examination can aid medical diagnosis in remote locations and may improve health inequalities between rural and urban settings. This review aimed to analyze the status of teleoperated robotic systems for ultrasound examinations, evaluate clinical and preclinical applications, identify limitations, and outline future directions for clinical use. Overall, robot-assisted teleoperated ultrasound is feasible and safe in the reported clinical and preclinical studies, with the robots able to follow the hand movements performed by sonographers and researchers from a distance or in local networks. Moreover, multiple types of ultrasound examinations have been performed in remote areas, with a high success rate nearly comparable to that of conventional sonography. The studies showed that although a low-bandwidth link can be used to control a robot, the bandwidth requirements for real-time transmission of video and ultrasound images are significantly higher. Furthermore, if haptic feedback is implemented, the bandwidth requirements are increased. Haptically enabled systems that improve robotic control are necessary for accelerating the introduction to clinical use. Haptic feedback and enhanced front-end interface control for remote users are vital aspects required for clinical application. The incorporation of artificial intelligence through either aiding in window acquisition (knowledge of anatomical landmarks to adjust scanning planes) or through measurement and disease identification is yet to be researched. However, it has the potential to lead to dramatic advances. A new generation of robots is in development, and several projects in the preclinical stage reveal a promising future to overcome the shortage of health professionals in remote areas.

Ultrasound assessments of organs and blood vessels before and after 40 days isolation in a cavern (deep time experiment 2021)

Introduction: Spaceflight simulation studies like confinement in small volume habitat with limited physical activity have reported even after 60 days an abnormal arterial wall adaptation with increase thickness or stiffness. The purpose of the current study was to determine the effects on blood vessel and organ structure of 40 days of isolation in a huge habitat with intensive physical activity. Method: Data were collected from 14 individuals (7 male) who isolated in a cavern for 40-days while performing normal daily activities without time references. Ultrasound assessments were performed pre- and post-isolation using a teleoperated system with eight different acoustic windows to obtain 19 measurements on 12 different organ/vascular structures which included the common carotid artery, femoral artery, tibial artery, jugular vein, portal vein, bile duct, kidney, pancreas, abdominal aorta, cervical and lumbar vertebral distance, and Achilles tendon. Results: Common carotid artery measures, including the intima media thickness, stiffness index, and the index of reflectivity measured from the radiofrequency signal, were not changed with isolation. Similarly, no differences were found for femoral artery measurements or measurements of any of the other organs/vessels assessed. There were no sex differences for any of the assessments. Discussion: Results from this study indicate a lack of physiological effects of 40-days of isolation in a cavern, contrary to what observed in previous 60 days confinement. This suggests a potential protective effect of sustained physical activity, or reduced environmental stress inside the huge volume of the confined facility.

Clinical application of a 5G-based telerobotic ultrasound system for thyroid examination on a rural island: a prospective study

PURPOSE

To evaluate the feasibility of a 5G-based telerobotic ultrasound (US) system for thyroid examination on a rural island.

METHODS

From September 2020 to March 2021, this prospectively study enrolled a total of 139 patients (average age, 58.6 ± 12.7 years) included 33 males and 106 females, who underwent 5G-based telerobotic thyroid US examination by a tele-doctor at Shanghai Tenth People's Hospital and a conventional thyroid US examination at Chongming Second People's Hospital 84 km away. The clinical feasibility of 5G-based telerobotic US for thyroid examination were evaluated in terms of safety, duration, US image quality, diagnostic results, and questionnaire survey.

RESULTS

92.8% of patients had no examination-related complaints. The average duration of the 5G-based telerobotic US examination was similar as that of conventional US examination (5.57 ± 2.20 min vs. 5.23 ± 2.1 min, P = 0.164). The image quality of telerobotic US correlated well with that of conventional US (4.63 ± 0.60 vs. 4.65 ± 0.61, P = 0.102). There was no significant difference between two types of US examination methods for the diameter measurement of the thyroid, cervical lymph nodes, and thyroid nodules. Two lymphadenopathies and 20 diffuse thyroid diseases were detected in two types of US methods. 124 thyroid nodules were detected by telerobotic US and 127 thyroid nodules were detected by conventional US. Among them, 122 were the same thyroid nodules. In addition, there were good consistency in the US features (component, echogenicity, shape, and calcification) and ACR TI-RADS category of the same thyroid nodules between telerobotic and conventional US examinations (ICC = 0.788-0.863). 85.6% of patients accepted the telerobotic US, and 87.1% were willing to pay extra fee for the telerobotic US.

CONCLUSION

The 5G-based telerobotic US system can be a routine diagnostic tool for thyroid examination for patients on a rural island.

Tele-ultrasound in the Era of COVID-19: A Practical Guide

Telemedicine has evolved over the past 50 years, with video consultations and telehealth (TH) mobile apps that are now widely used to support care in the management of chronic conditions, but are infrequently used in acute conditions such as emergencies. In the wake of the COVID-19 pandemic, demand is growing for video consultations as they minimize health provider-patient interactions and thereby the risk of infection. Advanced applications such as tele-ultrasound (TUS) have not yet gained a foothold despite their achieving technical maturity and the availability of software from numerous companies for TUS for their respective portable ultrasound devices. However, ultrasound is indispensable for triage in emergencies and also offers distinct advantages in the diagnosis of COVID-19 pneumonia for certain patient populations such as pregnant women, children and immobilized patients. Additionally, recent work suggests lung ultrasound can accurately risk stratify patients for likely infection when immediate polymerase chain reaction (PCR) testing is not available and has prognostic utility for positive patients with respect to the need for admission and intensive care unit (ICU) treatment. Though currently underutilized, a wider implementation of TUS in TH applications and processes may be an important stepping-stone for telemedicine. The addition of ultrasound to TH may allow it to cross the barrier from being an application used mainly for primary care and chronic conditions to an indispensable tool used in emergency care, disaster situations, remote areas and low-income countries where it is difficult to obtain high-quality diagnostic imaging. The objective of this review was to provide an overview of the current state of telemedicine, insights into current and future use scenarios, its practical application as well as current TUS uses and their potential value with an overview of currently available portable and handheld ultrasound devices. In the wake of the COVID-19 pandemic we point out an unmet need and use case of TUS as a supportive tool for health care providers and organizations in the management of affected patients.

A Telerobotic Ultrasound Clinic Model of Ultrasound Service Delivery to Improve Access to Imaging in Rural and Remote Communities

OBJECTIVE

Patients living in many rural and remote areas do not have readily available access to ultrasound services because of a lack of sonographers and radiologists in these communities. The objective of this study was to determine the feasibility of using telerobotic ultrasound to establish a service delivery model to remotely provide access to diagnostic ultrasound in rural and remote communities.

METHODS

Telerobotic ultrasound clinics were developed in three remote communities more than 500 km away from our academic medical center. Sonographers remotely performed all ultrasound examinations using telerobotic ultrasound systems, and examinations were subsequently interpreted by radiologists at an academic medical center. Diagnostic performance was assessed by each interpreting radiologist using a standardized reporting form. Patient experience was assessed through quantitative and qualitative analysis of survey responses. Operational challenges and solutions were identified.

RESULTS

Eighty-seven telerobotic ultrasound examinations were remotely performed and included in this study, with the most frequent examination types being abdominal (n = 35), first-trimester obstetrical (n = 26), and second-trimester complete obstetrical (n = 12). Across all examination types, 70% of telerobotic ultrasound examinations were sufficient for diagnosis, minimizing travel or reducing wait times for these patients. Ninety-five percent of patients would be willing to have another telerobotic ultrasound examination in the future. Operational challenges were related to technical infrastructure, human resources, and coordination between clinic sites.

CONCLUSION

Telerobotic ultrasound can provide access to diagnostic ultrasound services to underserved rural and remote communities without regular ultrasound services, thereby reducing disparities in access to care and improving health equity.

Development and assessment of a telesonography system for musculoskeletal imaging

Background

Telesonography systems have been developed to overcome barriers to accessing diagnostic ultrasound for patients in rural and remote communities. However, most previous telesonography systems have been designed for performing only abdominal and obstetrical exams. In this paper, we describe the development and assessment of a musculoskeletal (MSK) telesonography system.

Methods

We developed a 4-degrees-of-freedom (DOF) robot to manipulate an ultrasound probe. The robot was remotely controlled by a radiologist operating a joystick at the master site. The telesonography system was used to scan participants’ forearms, and all participants were conventionally scanned for comparison. Participants and radiologists were surveyed regarding their experience. Images from both scanning methods were independently assessed by an MSK radiologist.

Results

All ten ultrasound exams were successfully performed using our developed MSK telesonography system, with no significant delay in movement. The duration (mean ± standard deviation) of telerobotic and conventional exams was 4.6 ± 0.9 and 1.4 ± 0.5 min, respectively (p = 0.039). An MSK radiologist rated quality of real-time ultrasound images transmitted over an internet connection as “very good” for all telesonography exams, and participants rated communication with the radiologist as “very good” or “good” for all exams. Visualisation of anatomic structures was similar between telerobotic and conventional methods, with no statistically significant differences.

Conclusions

The MSK telesonography system developed in this study is feasible for performing soft tissue ultrasound exams. The advancement of this system may allow MSK ultrasound exams to be performed over long distances, increasing access to ultrasound for patients in rural and remote communities.

Telerobotic Sonography for Remote Diagnostic Imaging: Narrative Review of Current Developments and Clinical Applications

Access to sonographers and sonologists is limited in many communities around the world. Telerobotic sonography (robotic ultrasound) is a new technology to increase access to sonography, providing sonographers and sonologists the ability to manipulate an ultrasound probe from a distant location and remotely perform ultrasound examinations. This narrative review discusses the development of telerobotic ultrasound systems, clinical studies evaluating the feasibility and diagnostic accuracy of telerobotic sonography, and emerging use of telerobotic sonography in clinical settings. Telerobotic sonography provides an opportunity to provide real-time ultrasound examinations to underserviced rural and remote communities to increase equity in the delivery of diagnostic imaging.

Medical Robotics for Ultrasound Imaging: Current Systems and Future Trends

Purpose of Review

This review provides an overview of the most recent robotic ultrasound systems that have contemporary emerged over the past five years, highlighting their status and future directions. The systems are categorized based on their level of robot autonomy (LORA).

Recent Findings

Teleoperating systems show the highest level of technical maturity. Collaborative assisting and autonomous systems are still in the research phase, with a focus on ultrasound image processing and force adaptation strategies. However, missing key factors are clinical studies and appropriate safety strategies. Future research will likely focus on artificial intelligence and virtual/augmented reality to improve image understanding and ergonomics.

Summary

A review on robotic ultrasound systems is presented in which first technical specifications are outlined. Hereafter, the literature of the past five years is subdivided into teleoperation, collaborative assistance, or autonomous systems based on LORA. Finally, future trends for robotic ultrasound systems are reviewed with a focus on artificial intelligence and virtual/augmented reality.

Mobile Health Applications for Prenatal Assessment and Monitoring

BACKGROUND

A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care.

METHODS

In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care.

RESULTS

Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable.

CONCLUSIONS

Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology.

Remote Echography between a Ground Control Center and the International Space Station Using a Tele-operated Echograph with Motorized Probe

Echography is the most appropriate imaging modality for investigating astronauts. Unfortunately, it requires a great deal of training to perform ultrasound examinations, which can be difficult and time consuming, especially if the astronaut does not have a medical background. We designed a new echography system with motorized probes that allows for the majority of exam functions to be controlled by a ground-based sonographer. Using tele-operation, the sonographer controls the orientation of the transducer (tilt, rotation) and echograph settings (gain, depth, freeze) and triggers ultrasound functions (pulsed wave color Doppler, 3-D capture, radiofrequency data collection, elastography). With this system, astronauts are required to hold the motorized probe only at the locations indicated, with the remainder of the exam being conducted by the ground-based sonographer. During spaceflight, ultrasound imaging of the carotid artery, jugular vein, thyroid, liver, gallbladder, biliary tract and portal vein (2-D, 3-D, color, pulsed wave, radiofrequency) were successfully performed.

A Crossover Comparison of Standard and Telerobotic Approaches to Prenatal Sonography

OBJECTIVES

To determine the feasibility of a telerobotic approach to remotely perform prenatal sonographic examinations.

METHODS

Thirty participants were prospectively recruited. Participants underwent a limited examination (assessing biometry, placental location, and amniotic fluid; n = 20) or a detailed examination (biometry, placental location, amniotic fluid, and fetal anatomic survey; n = 10) performed with a conventional ultrasound system. This examination was followed by an equivalent examination performed with a telerobotic ultrasound system, which enabled sonographers to remotely control all ultrasound settings and fine movements of the ultrasound transducer from a distance. Telerobotic images were read independently from conventional images.

RESULTS

The mean gestational age ± SD of the 30 participants was 22.9 ± 5.3 weeks. Paired-sample t tests showed no statistically significant difference between conventional and telerobotic measurements of fetal head circumference, biparietal diameter, or single deepest vertical pocket of amniotic fluid; however, a small but statistically significant difference was observed in measurements of abdominal circumference and femur length (P < .05). Intraclass correlations showed excellent agreement (>0.90) between telerobotic and conventional measurements of all 4 biometric parameters. Of 21 fetal structures included in the anatomic survey, 80% of the structures attempted across all patients were sufficiently visualized by the telerobotic system (range, 57%-100% per patient). Ninety-seven percent of patients strongly or somewhat agreed that they would be willing to have another telerobotic examination in the future.

CONCLUSIONS

A telerobotic approach is feasible for remotely performing prenatal sonographic examinations. Telerobotic sonography (robotic telesonography) may allow for the development of satellite ultrasound clinics in rural, remote, or low-volume communities, thereby increasing access to prenatal imaging in underserved communities.

Tele-Operated Echography and Remote Guidance for Performing Tele-Echography on Geographically Isolated Patients

Objective: To evaluate the performance of three tele-echography systems for routine use in isolated medical centers. Methods: Three systems were used for deep (abdomen, pelvis, fetal) and superficial (muscle, thyroid, carotid artery) examinations: (a) a robotic arm (RA) holding an echographic probe; (b) an echograph with a motorized probe (MP); and (c) remote guidance (RG) where the patient site operator performed the examination assisted by an expert via videoconference. All systems were tested in the same medical center located 60 km away from the university hospital. Results: A total of 340 remote echography examinations were performed (41% RA and MP, 59% RG). MP and RA allowed full control of the probe orientation by the expert, and provided diagnoses in 97% of cases. The use of RG was sufficient for superficial vessel examinations and provided diagnoses in 98% of cases but was not suited for deep or superficial organs. Assessment of superficial organs was best accomplished using the MP. Discussion: Both teleoperated systems provided control of the probe orientation by the expert necessary for obtaining appropriate views of deep organs but the MP was much more ergonomic and easier to use than the RA. RG was appropriate for superficial vessels while the MP was better for superficial volumic organs.