Testing telediagnostic thyroid ultrasound in Peru: a new horizon in expanding access to imaging in rural and underserved areas

PURPOSE

Thyroid ultrasound is a key tool in the evaluation of the thyroid, but billions of people around the world lack access to ultrasound imaging. In this study, we tested an asynchronous telediagnostic ultrasound system operated by individuals without prior ultrasound training which may be used to effectively evaluate the thyroid and improve access to imaging worldwide.

METHODS

The telediagnostic system in this study utilizes volume sweep imaging (VSI), an imaging technique in which the operator scans the target region with simple sweeps of the ultrasound probe based on external body landmarks. Sweeps are recorded and saved as video clips for later interpretation by an expert. Two operators without prior ultrasound experience underwent 8 h of training on the thyroid VSI protocol and the operation of the telemedicine platform. After training, the operators scanned patients at a health center in Lima. Telediagnostic examinations were sent to the United States for remote interpretation. Standard of care thyroid ultrasound was performed by an experienced radiologist at the time of VSI examination to serve as a reference standard.

RESULTS

Novice operators scanned 121 subjects with the thyroid VSI protocol. Of these exams, 88% were rated of excellent image quality showing complete or near complete thyroid visualization. There was 98.3% agreement on thyroid nodule presence between VSI teleultrasound and standard of care ultrasound (Cohen's kappa 0.91, P < 0.0001). VSI measured the thyroid size, on average, within 5 mm compared to standard of care. Readers of VSI were also able to effectively characterize thyroid nodules, and there was no significant difference in measurement of thyroid nodule size (P = 0.74) between VSI and standard of care.

CONCLUSION

Thyroid VSI telediagnostic ultrasound demonstrated both excellent visualization of the thyroid gland and agreement with standard of care thyroid ultrasound for nodules and thyroid size evaluation. This system could be deployed for evaluation of palpable thyroid abnormalities, nodule follow-up, and epidemiological studies to promote global health and improve the availability of diagnostic imaging in underserved communities.

Testing telediagnostic right upper quadrant abdominal ultrasound in Peru: A new horizon in expanding access to imaging in rural and underserved areas

Background

Hepatic and biliary diseases are prevalent worldwide, but the majority of people lack access to diagnostic medical imaging for their assessment. The liver and gallbladder are readily amenable to sonographic examination, and ultrasound is a portable, cost-effective imaging modality suitable for use in rural and underserved areas. However, the deployment of ultrasound in these settings is limited by the lack of experienced sonographers to perform the exam. In this study, we tested an asynchronous telediagnostic system for right upper quadrant abdominal ultrasound examination operated by individuals without prior ultrasound experience to facilitate deployment of ultrasound to rural and underserved areas.

Methods

The teleultrasound system utilized in this study employs volume sweep imaging and a telemedicine app installed on a tablet which connects to an ultrasound machine. Volume sweep imaging is an ultrasound technique in which an individual scans the target region utilizing preset ultrasound sweeps demarcated by easily recognized external body landmarks. The sweeps are saved as video clips for later interpretation by an experienced radiologist. Teleultrasound scans from a Peruvian clinic obtained by individuals without prior ultrasound experience were sent to the United States for remote interpretation and quality assessment. Standard of care comparison was made to a same-day ultrasound examination performed by a radiologist.

Results

Individuals without prior ultrasound experience scanned 144 subjects. Image quality was rated “poor” on 36.8% of exams, “acceptable” on 38.9% of exams, and “excellent” on 24.3% of exams. Among telemedicine exams of “acceptable” or “excellent” image quality (n = 91), greater than 80% of the liver and gallbladder were visualized in the majority of cases. In this group, there was 95% agreement between standard of care and teleultrasound on whether an exam was normal or abnormal, with a Cohen’s kappa of 0.84 (95% CI 0.7–0.98, p <0.0001). Finally, among these teleultrasound exams of “acceptable” or “excellent” image quality, the sensitivity for cholelithiasis was 93% (95% CI 68.1%-99.8%), and the specificity was 97% (95% CI 89.5%-99.6%).

Conclusion

This asynchronous telediagnostic system allows individuals without prior ultrasound experience to effectively scan the liver, gallbladder, and right kidney with a high degree of agreement with standard of care ultrasound. This system can be deployed to improve access to diagnostic imaging in low-resource areas.

Testing telediagnostic obstetric ultrasound in Peru: a new horizon in expanding access to prenatal ultrasound

Background

Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist.

Methods

This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen’s Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables.

Results

Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81–0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound.

Conclusion

This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03720-w.

New Ultrasound Telediagnostic System for Low-Resource Areas: Pilot Results From Peru

Billions of people around the world lack access to diagnostic imaging. To address this issue, we piloted a comprehensive ultrasound telediagnostic system, which uses ultrasound volume sweep imaging (VSI) acquisitions capable of being performed by operators without prior traditional ultrasound training and new telemedicine software capable of sending imaging acquisitions asynchronously over low Internet bandwidth for remote interpretation. The telediagnostic system was tested with obstetric, right upper quadrant abdominal, and thyroid volume sweep imaging protocols in Peru. Scans obtained by operators without prior ultrasound experience were sent for remote interpretation by specialists using the telemedicine platform. Scans obtained allowed visualization of the target region in 96% of cases with diagnostic imaging quality. This telediagnostic system shows promise in improving health care disparities in the developing world.

Need for the Development of a Specific Regulatory Framework for Evaluation of Mobile Health Apps in Peru: Systematic Search on App Stores and Content Analysis

Background

In Peru, there is an increase in the creation of mobile health (mHealth) apps; however, this situation could present problems related to the quality of information these apps share, data security and privacy, usability, and effectiveness, as there is no specific local regulation about their creation and use.

Objective

The objective of this study was to review mHealth apps created, uploaded, or used in Peru, and perform an analysis of the national regulatory framework that could be applied to evaluate whether there is a need to develop and implement a specific regulation to these apps.

Methods

A total of 3 reviews were performed. First, we reviewed information about Peruvian mHealth apps created up to May 2019 from scientific publications, news, government communications, and virtual stores, and evaluated their purpose, creator, and the available evidence of their usability and effectiveness. The second review was carried out by taking a sample of the 10 most commonly used mHealth apps in Peru (regardless of the country of creation), to evaluate the information they collect and classify them according to the possible risks that they could present in terms of security and privacy. In addition, we evaluated whether they refer to or endorse the information they provided. Finally, in the third review, we searched for Peruvian standards related to electronic health (eHealth) that involve information technology that can be applied to regulate these apps.

Results

A total of 66 apps meeting our inclusion criteria were identified; of these, 47% (n=31) belonged to government agencies and 47% (n=31) were designed for administrative purposes (private and government agencies). There was no evidence about the usability or effectiveness of any of these apps. Concerning the 10 most commonly used mHealth apps in Peru, about the half of them gathered user information that could be leaked, changed, or lost, thus posing a great harm to their users or to their related patients. In addition, 6/10 (60%) of these apps did not mention the source of the information they provided. Among the Peruvian norms, the Law on the Protection of Personal Data, Law on Medical Devices, and administrative directives on standards and criteria for health information systems have some regulations that could be applied to these apps; however, these do not fully cover all aspects concerning the evaluation of security and privacy of data, quality of provided information, and evidence of an app’s usability and effectiveness.

Conclusions

Because many Peruvian mHealth apps have issues related to security and privacy of data, quality of information provided, and lack of available evidence of their usability and effectiveness, there is an urgent need to develop a regulatory framework based on existing medical device and health information system norms in order to promote the evaluation and regulation of all the aforesaid aspects, including the creation of a national repository for these apps that describes all these characteristics.

The odyssey of linking to and staying in HIV care among male sex workers in Peru

BACKGROUND

In Peru, there is little information about the HIV care continuum. Therefore, we conducted a study to describe the HIV care continuum among male sex workers (MSWs) in Lima.

METHODS

We applied close-ended surveys with 209 MSWs about their engagement in the HIV care continuum and open-ended surveys with 34 MSWs who are people living with HIV (PLHIV) to explore their linkage to and retention in HIV care.

RESULTS

Of 209 MSWs, only 71% (n=148) reported a lifetime HIV test and 56% (n=116) of all MSWs received confirmatory HIV test results. Of the 34 MSWs who are PLHIV, 76% had received HIV care at least once, but only 59% were currently in care, 50% were currently taking ART(antiretroviral therapy) and an even lower 32% had been on ART for 6 months or more. The primary reason for non-linkage to HIV care is the multiple visits to link at the Ministry of Health (MOH). Remaining in care was also challenging, particularly at non-governmental organizations (NGOs).

CONCLUSIONS

Substantial barriers linking to and remaining in HIV care result in significant delays in linkage and high proportions of PLHIV that remain unlinked or become unstably linked following initial linkage. Urgent implementation science research is needed to facilitate linkage to HIV care and strengthen retention in HIV care post-linkage.

[Development and institutionalization of the first online certificate and Master Program of Biomedical Informatics in global health in Peru]

Training in Biomedical Informatics is essential to meet the challenges of a globalized world. However, the development of postgraduate training and research programs in this area are scarce in Latin America. Through QUIPU: Andean Center for Training and research in Iformatics for Global Health, has developed the first Certificate and Master’s Program on Biomedical Informatics in the Andean Region. The aim of this article is to describe the experience of the program. To date, 51 students from Peru, Chile, Ecuador, Colombia and Venezuela have participated; they come from health ministries, hospitals, universities, research centers, professional associations and private companies. Seventeen courses were offered with the participation of faculty from Argentina, Chile, Colombia, USA, Mexico and Peru. This program is already institutionalized at the School of Public Health and Administration from the Universidad Peruana Cayetano Heredia.