Remote Care Settings Research Articles

Introduction and Validation of Low-Cost Ocular Biometry in Healthy and Cataractous Eyes Using a Thermally Tunable Swept-Source Laser

To introduce and validate a novel substantially lower-priced and rapid swept-source investigational optical biometer in healthy and cataractous eyes, using a thermally tuned laser diode used extensively in cell phones and data communication as an alternative swept source. Prospective accuracy, validity, and reliability analysis. A total of 60 eyes of 59 subjects (29 eyes of 29 healthy subjects and 31 eyes of 30 cataract patients) were enrolled in a prospective comparative study at the Vienna General Hospital between August 2021 and April 2023. Averaged intraocular distances were acquired in 2.5 seconds from datasets consisting of 5000 consecutive A-scans at a single position by a low-cost swept-source optical biometry (SSOB) system. Instrument repeatability was assessed via standard deviations (SDs) and coefficients of variation (CoVs) of parameters such as axial length (AL), anterior chamber depth (ACD), lens thickness (LT), and central corneal thickness (CCT). Healthy subjects and cataract patients were subsequently measured on the same day with the SSOB and a referential partial coherence interferometry (PCI) biometer (IOLMaster 500) to establish AL inter-device correlation (r) for instrument calibration. AL and ACD as shared parameters between both biometers were evaluated for their limits of agreements (LoA) using Bland-Altman analysis. Repeated measurements of AL, ACD, LT, and CCT revealed SDs of 18 µm, 12 µm, 12 µm, and 10 µm, respectively. All parameters except for CCT had a COV <1%. Except for 1 eye with white cataract, 59 eyes of 59 study participants with various degrees and types of cataract could be measured with both devices. The AL inter-device correlation was excellent (r > 0.99). The 95% LoAs between both biometers were -0.14 to 0.13 mm for AL and -0.28 to 0.25 mm for ACD. Optical biometry using a thermally tunable VCSEL swept-source light source has the potential to provide clinically relevant biometric parameters at an unprecedented 100-fold lower price point than currently used state-of-the-art optical biometers, paving the way for compact devices in remote care settings.

Crisis and curfew: Lived experiences of community members seeking emergency maternal and neonatal care before and during the COVID-19 pandemic on Mfangano Island, Lake Victoria, Kenya

Prior to the COVID-19 pandemic, families in rural sub-Saharan Africa faced numerous well-documented barriers in accessing timely care during maternal and neonatal health emergencies. We are now beginning to further appreciate the complex impacts that global disruptions, like the COVID-19 pandemic, can have on access to maternal care across vulnerable health systems, particularly for mothers seeking care in remote settings. In 2021, we initiated a qualitative follow-up study to the MOMENTUM (Monitoring Maternal Emergency Navigation and Triage on Mfangano) cohort study conducted within the remote communities of Mfangano Island on Lake Victoria, in Western Kenya, in 2019 and early 2020. Given the timing of this follow-up study, we sought to further qualify the barriers previously identified during the initial MOMENTUM quantitative survey, as well as explore specific ways that the COVID-19 pandemic impacted these barriers. In September 2021, 4 Focus Group Discussions (FGDs), with a total of 44 participants, were conducted among patients and families who had recently experienced maternal and neonatal emergencies. Additionally, 15 Key Informant Interviews (KIIs) were conducted with community leaders and health-care providers to allow reflection more broadly on their local emergency health-care system. A grounded theory methodology was utilized to analyze respondent themes. The lived experiences reported here by FGD and KII participants substantiate and validate numerous challenges previously identified in our prior study. Importantly, participants also highlighted specific ways that the pandemic intensified each of these factors, through the spread of misinformation, restricted mobility due to government curfews and lockdowns, increased frequency of health worker strikes, and worsening financial and resource constraints across the health system. Participants also described creative ways in which contextually experienced providers (i.e., Mfangano Health Navigators) facilitated critical coordination to help patients access care during the chaotic circumstances generated by the pandemic. These findings suggest that trained community health workers can play an influential role in improving emergency care coordination, particularly during future pandemics and similar public health disruptions within extremely resource-limited environments.

Understanding social dynamics and patient experience in out of hospital care: validation of a co-responsibility questionnaire (CoReCare)

Patient experiences are commonly assessed through patient reported experience measures (PREMs). Ambulatory care models extend traditional care into the patients’ home, meaning that a triangle of health care professionals, patients, and their families need to be considered when assessing the remote care experience. These intertwined responsibilities are described by co-responsibility. Currently, PREMs don’t reflect how elements to remote care impact this remote care experience. Therefore, this study aimed to develop a questionnaire assessing perceived patient-partner co-responsibility as a PREM in remote care. A 30-item questionnaire was assessed among 1000 individuals aged between 18 and 65 years that tried to lose weight with a partner, friend or family member supporting them. Pairwise item correlations, Exploratory Factor Analysis, and Cronbach’s alpha were used for validation. 29-items were identified to reflect co-responsibility across 6 factors: empowerment and support, relational aspects, lack of sympathy, co-participation, accepting help and awareness. Cronbach’s alpha ranged between 0.66 and 0.93, showing good internal consistency. We present a validated CoReCare Questionnaire to understand the impact of social dynamics on achieving desired health outcomes in a remote care setting. The CoReCare Questionnaire extends current PREMs when aiming to assess and improve the patient experience of a care episode outside of the hospital.

EEG electrode localization with 3D iPhone scanning using point-cloud electrode selection (PC-ES)

Objective. Electroencephalography source imaging (ESI) is a valuable tool in clinical evaluation for epilepsy patients but is underutilized in part due to sensitivity to anatomical modeling errors. Accurate localization of scalp electrodes is instrumental to ESI, but existing localization devices are expensive and not portable. As a result, electrode localization challenges further impede access to ESI, particularly in inpatient and intensive care settings. Approach. To address this challenge, we present a portable and affordable electrode digitization method using the 3D scanning feature in modern iPhone models. This technique combines iPhone scanning with semi-automated image processing using point-cloud electrode selection (PC-ES), a custom MATLAB desktop application. We compare iPhone electrode localization to state-of-the-art photogrammetry technology in a human study with over 6000 electrodes labeled using each method. We also characterize the performance of PC-ES with respect to head location and examine the relative impact of different algorithm parameters. Main Results. The median electrode position variation across reviewers was 1.50 mm for PC-ES scanning and 0.53 mm for photogrammetry, and the average median distance between PC-ES and photogrammetry electrodes was 3.4 mm. These metrics demonstrate comparable performance of iPhone/PC-ES scanning to currently available technology and sufficient accuracy for ESI. Significance. Low cost, portable electrode localization using iPhone scanning removes barriers to ESI in inpatient, outpatient, and remote care settings. While PC-ES has current limitations in user bias and processing time, we anticipate these will improve with software automation techniques as well as future developments in iPhone 3D scanning technology.

Relevance of Teledentistry: Brief Report and Future Perspectives.

Teledentistry is a type of telemedicine and telehealth that aims to make all major specialties of the discipline easier through a remote approach to prevention and treatment of oral and dental issues. This new method enables distant access to individuals instead of direct, face-to-face, doctor-patient contact and has been made possible thanks to developments in information technology. Teledentistry was described in 1997 as "… the practice of using video-conferencing technologies to diagnose and provide advice about treatment over a distance", and today it represents a modern way to practice dentistry by integrating digital imaging, electronics, health records, and telecommunications technology via an internet connection. This approach facilitates patients' access to care in remote settings and also enables specialists at distant locations to arrive at a correct diagnosis as well as to propose proper therapy or refer patients, where warranted. The current brief report aims to describe the present and future of this modern approach in dentistry and its advantages in patient management from prevention to diagnosis to treatment.

Automated multilabel diagnosis on electrocardiographic images and signals

The application of artificial intelligence (AI) for automated diagnosis of electrocardiograms (ECGs) can improve care in remote settings but is limited by the reliance on infrequently available signal-based data. We report the development of a multilabel automated diagnosis model for electrocardiographic images, more suitable for broader use. A total of 2,228,236 12-lead ECGs signals from 811 municipalities in Brazil are transformed to ECG images in varying lead conformations to train a convolutional neural network (CNN) identifying 6 physician-defined clinical labels spanning rhythm and conduction disorders, and a hidden label for gender. The image-based model performs well on a distinct test set validated by at least two cardiologists (average AUROC 0.99, AUPRC 0.86), an external validation set of 21,785 ECGs from Germany (average AUROC 0.97, AUPRC 0.73), and printed ECGs, with performance superior to signal-based models, and learning clinically relevant cues based on Grad-CAM. The model allows the application of AI to ECGs across broad settings.

Training novice users to assess stroke aetiology in remote settings using transcranial ultrasound: pilot study.

Emergency care delivery to patients in remote and rural areas is limited by diagnostic restrictions and long transport times to major centres of care. People with suspected acute stroke living long distances from a hospital are unlikely to receive time-critical reperfusion therapy for these reasons. Basic brain imaging assessing blood flow in the major intracranial arteries could facilitate such care in remote settings. A 3-hour training package for novice transcranial ultrasound users has been piloted on a small group of volunteers to investigate whether they could acquire transcranial ultrasound images and video clips to potentially allow remote interpretation and optimise pre-hospital management of acute stroke. A pilot training project was set up in a university setting in Inverness, Scotland. Volunteer clinicians and students of nursing or medicine with no practical experience in transcranial ultrasound were recruited. Participants received three 1-hour training sessions combining theoretical aspects and hands-on practice on healthy volunteers provided by a qualified neurologist with more than 2 years of experience in transcranial ultrasound. Transcranial greyscale and colour-coded duplex sonography was performed to visualise midline structures and major intracranial vessels, and to measure blood flow velocity in the middle cerebral artery, followed by an unsupervised assessment. Qualitative analysis of the anonymised feedback from participants on the training experience and its potential application was also performed. A total of 11 volunteers were recruited in the current pilot study. The average time to complete transcranial ultrasound assessment was approximately 40 minutes. The brain midline and cerebral peduncles were correctly labelled by 64% (7/11) and 91% (10/11) of volunteers, respectively. Participants demonstrated a good performance in detecting major intracranial vessels. The correct labelling rate for the middle cerebral artery was 73% (8/11), and 64% (7/11) for the anterior and posterior cerebral arteries. There was agreement between the trainer and the participants on rating the quality of scans as assessed using a visual analogue scale. All participants gave positive feedback on the provided training and time allocated for each session. Generally, volunteers thought that operating the ultrasound machine and the probe simultaneously was difficult. It was also suggested that further follow-up training, with possible supervision, would be useful to retain the acquired skills. Transcranial ultrasound scans of a quality to allow expert interpretation can be acquired by inexperienced transcranial ultrasound operators after receiving a brief training. This could potentially be used by medical staff working in remote and rural areas to facilitate acute care for stroke patients, but further work with a larger sample is needed.

Clonidine for pain-related distress in Aboriginal children on a penicillin regimen to prevent recurrence of rheumatic fever.

Indigenous children and adolescents in Australia and globally bear the burden of acute rheumatic fever (ARF). It has been virtually eliminated in well-resourced, developed settings. ARF is an autoimmune response to infection with group A Streptococcus. The mainstay of management is long-acting intramuscular penicillin injections to prevent recurrence of ARF and development of rheumatic heart disease (RHD), comprising valvular pathology and attendant complications. In Australia, penicillin injections are currently prescribed every 28 days for 5-10 years after diagnosis of ARF, depending on cardiac involvement. Adherence to this regimen reduces ARF recurrences and RHD progression. 'Days at risk' of ARF recurrence are calculated as the number of days after day 28 that an injection is not received. Adherence to the injection schedule has been reported as difficult in most global locations due to the painful nature of the injections, the long timeframes of the prescription, young age of patients, access problems and costs in some locations. The newly updated Australian guideline on the prevention, diagnosis and management of ARF and RHD has a chapter dedicated to secondary prophylaxis. This chapter takes into account cultural considerations and advises on ways to minimise pain and distress of injections in children such as pain gate strategies, distraction techniques and concurrent injection of local anaesthetic. Some children continue to find the injection regimen traumatising despite strategies to reduce pain and fear. Clinicians providing the injections to children also find the injecting episodes distressing if pain is not effectively minimised. An Aboriginal Community Controlled Health Service in a remote setting in northern Australia addressed the issue of severe trauma of injection episodes experienced by an Aboriginal boy aged 7 years. Usual strategies were not effective, so advice was sought from an expert anaesthetist at a tertiary hospital. As a result, oral clonidine 3 &micro;g/kg was trialled 45 minutes prior to the penicillin injection. Procedural coaching and monitoring protocols specific to administration of clonidine in children under their care were created by the health service. The initial dose of clonidine was delivered with the child as an inpatient. Clonidine was successful in reducing pain related distress and facilitating adherence to the penicillin regimen. Subsequent doses were delivered and monitored in a remote setting by nurses. After 18 months, the boy no longer required clonidine due to his increased coping capacity. A second child was recognised with similar trauma and has been taking clonidine for pre-procedural sedation for 6 months with good effect and no adverse effects. An additional child was similarly prescribed clonidine without success. Failure in that instance was attributed to lack of procedural coaching and receiving the initial dose of clonidine in an emergency department in hurried circumstances. Individualised child-focused and culturally appropriate care in remote settings is feasible: in this instance team planning for use of clonidine and procedural coaching when other measures have failed. However, for children with RHD, or other comorbidities, advice from the child's treating cardiologist is required prior to prescribing clonidine due to possible adverse consequences. These include hypotension and atrioventricular block, which could lead to haemodynamic compromise in the setting of moderate to severe RHD.

CT of the head for acute stroke: Diagnostic performance of a tablet computer prior to intravenous thrombolysis.

The authors propose that tablet computers could benefit patients with acute stroke in the remote care setting, where time to and accuracy of CT interpretation greatly influences patient outcome. One hundred and fifty consecutive patients who presented to the Emergency Department of a tertiary referral neurosciences centre within a time window suitable for intravenous thrombolytic therapy were included. Images were wirelessly transmitted to a tablet computer (iPad 3rd Generation, model=A1430, Apple, Cupertino, CA) and were reviewed by radiologists with three levels of experience for signs of intracranial haemorrhage, large vessel occlusion and parenchymal infarction. Reference standard interpretation was performed by two neuroradiologists using a diagnostic monochrome display. Consensus neuroradiologist review on the tablet display found and correctly classified all of the 23 cases of intracranial haemorrhage including 21 cases of parenchymal haematoma, two cases of petechial haemorrhage and one patient with an acute subdural haematoma. Less experienced readers missed cases of petechial and subdural haematomas. There was excellent agreement between the tablet and diagnostic monochrome display in cases with no infarct or extensive parenchymal infarction. Tablet computers can be used to facilitate rapid preliminary CT interpretation in patients with acute stroke in the remote setting.

Cost-effectiveness of short-term neurosurgical missions relative to other surgical specialties

Background:Short-term surgical relief efforts have helped close some gaps in the provision of surgical care in remote settings. We reviewed the published literature on short-term surgical missions to compare their cost-effectiveness across subspecialties.Methods:PubMed was searched using the algorithm [“cost-effectiveness” AND “surgery” AND (“mission” OR “volunteer”)]. Articles detailing the cost-effectiveness of short-term surgical missions in low and middle-income countries (LMIC) were included. Only direct mission costs were considered, and all costs were converted into 2014 USD.Results:Eight articles, representing 27 missions in 9 LMIC countries during 2006–2014, met our inclusion criteria. Latin America was the most frequently visited region. Per capita costs ranged from $259 for cleft lip/cleft palate (CL/CP) missions to $2900 for a neurosurgery mission. Mission effectiveness ranged from 3 disability adjusted life years (DALYs) averted per patient for orthopedic surgery missions to 8.12 DALYs averted per patient for a neurosurgery mission. CL/CP and general surgery missions were the most cost-effective, averaging $80/DALY and $87/DALY, respectively. The neurosurgical, orthopedic, and hand surgery missions averaged the highest costs/DALY averted, with the cost-effectiveness being $357/DALY, $435/DALY, and $445/DALY, respectively. All analyzed missions were very cost effective.Conclusion:To date, this is the first study to assess the cost-effectiveness of short-term surgical missions across surgical specialties. Neurosurgical missions avert the largest number of healthy life years compared to other specialties, and thus, could yield a greater long-term benefit to resource-poor communities. We recommend that further studies be carried out to assess the impact of surgical missions in low-resource settings.

Ambulance referral for emergency obstetric care in remote settings.

To evaluate the functionality of an ambulance service dedicated to emergency obstetric care (EmOC) that referred pregnant women to health centers for delivery assistance or to a hospital for the management of obstetric complications. A retrospective study investigated an ambulance referral system for EmOC in a rural area of Ethiopia between July 1 and December 31, 2013. The service was available 24h a day and was free of charge. Women requesting referral were transported to nearby health centers. Assistance was provided locally for uncomplicated deliveries. Women with obstetric complications were referred from health centers to a hospital. A total of 528 ambulance referrals were recorded. The majority of patients (314 [59.5%]) were transported from villages to health centers. The remaining individuals were brought to a hospital, having been referred from health centers (179 [33.9%]) or were referred directly from villages owing to hospital proximity (35 [6.6%]). Of the 179 patients referred to the hospital from health centers, 84 (46.9%) were diagnosed with major direct obstetric complications. No maternal deaths were recorded among patients using the ambulance service. The cost of the ambulance service was US$ 18.47 per referred patient. An ambulance service dedicated to EmOC that interconnected health centers and a hospital facilitated referrals and better utilized local resources.

Promoting women's health in remote Aboriginal settings: Midwifery students' insights for practice.

To describe midwifery students' insights on promoting health to Aboriginal women in remote Australia following a supervised clinical placement. Semistructured, in-depth interviews were conducted with all midwifery students who undertook the placement between 2010 and 2013. Aboriginal communities on the Ngaanyatjarra Lands, Western Australia. Undergraduate and postgraduate midwifery students from a Western Australian university. Remote cultural immersion clinical placement. Student learning related to culturally respectful health care delivery and promotion of health. Students observed that, despite vast distances, high rates of participation in a breast screening program were achieved due to the informal provision of culturally relevant information and support. Opportunistic encounters in communities also enabled sexual health messages to be delivered more widely and in less formal settings. The role played by Aboriginal Health Workers and female family members was vital. The importance of culturally respectful approaches to sensitive women's business, including discretion, the use of local language and pictorial representations of information, was recognised as was the socio-cultural context and its impact on the health and well-being of the community. Although short in duration, the Ngaanyatjarra Lands clinical placement provided midwifery students with a rare opportunity to observe the importance of local contexts and cultural protocols in Aboriginal communities, and to adapt health promotion strategies to meet local needs and ways of doing things. These strategies embraced the strengths, assets and capacities of communities, yet students also witnessed challenges associated with access, delivery and acceptance of health care in remote settings.

Smartphones in the Wild: Can Technology Improve Emergency Care in Remote Settings?

Environmental illness and injury in the wilderness can occur quickly and unexpectedly, requiring a swift response with limited resources. Remote locations inhibit communication and outside support, leading to extended time to definitive care. That results in greater responsibility for first responders. A mobile application with protocol for wilderness issues may help providers with limited knowledge to manage medical emergencies until professional medical care is possible. Improvement in first responder care can also decrease emergency medical services and hospital costs, in addition to preventing long-term complications. The purpose of this study is to determine, by simulated scenario performance, whether the use of a smartphone application will improve management of common medical emergencies in the wilderness. We identified the top-rated survival and first aid applications available in the iPhone and Android digital application markets. We designed 6 emergency scenarios set in a wilderness context with performance based on standard criteria outlined in Auerbach’s Wilderness Medicine textbook. Using a prospective study, we compared patient care performance between simulations that were application assisted and simulations that were not. A population of 66 simulations of 6 scenarios completed by 11 inexperienced students provided a 64% power to detect a difference of 50% in the improvement of scores when using the wilderness medicine application. Interrater reliability was also calculated on a subset of the stations. Performance on simulations did not vary with smartphone application use, according to t test (P = .296). Smartphone applications theoretically provide accessible knowledge for inexperienced first responders in remote settings. Our study suggests an opening in the smartphone application market for an effective wilderness survival tool. Furthermore, lack of training in basic first aid may not be compensated for by smartphone application help. We plan to extend this study to include more participants.

Perspectives of Indigenous people in the Pilbara about the delivery of healthcare services

To identify Indigenous people's views about gaps and practical solutions for the delivery of healthcare services in the Pilbara. A structured guide was used to interview three Indigenous language groups from the Pilbara region of Western Australia. The responses were analysed with the use of content analysis. In the first stage, codes were developed by assigning names to small sections of the interview transcripts. Next, the most salient incisive codes were identified and developed into themes that captured the most important issues. Many respondents said that there were insufficient health professionals near country, which was compounded by a lack of adequate transport to reach healthcare services. Moreover, respondents commonly indicated that they would be unable to secure adequate accommodation for themselves and any carer when needing to leave country to undergo medical care. The importance of secondary healthcare interventions was highlighted, particularly health promotion initiatives that improved diet and exercise levels and reduced substance abuse. Assuming responsibility for one's own health was seen as integral to improving the overall health of communities. The respondents saw role models as the most important influence in leading people to take responsibility for improving their own health. This study provides Indigenous perspectives about gaps and solutions in healthcare service delivery in the Pilbara region of Western Australia. Although initiatives have commenced to address the shortfall in health professionals and inadequate transport to healthcare, there are still gaps in service provision. Mobile health services were strongly supported as an integral measure to address these gaps. WHAT IS KNOWN ABOUT THIS TOPIC? About two out of every three Indigenous adults in the Pilbara experience a chronic health condition. Moreover, compared with non-Indigenous people in the region, Indigenous people experience a significantly higher mortality rate for numerous chronic health conditions. Although some information is available about the provision of health services for Indigenous people in the Pilbara, little is known about Indigenous people's perspectives about its adequacy or how it should be delivered. WHAT DOES THIS PAPER ADD? This study details three local language groups' views about the gaps and solutions to delivery of healthcare for Indigenous people in the Pilbara. It highlights the need for secondary healthcare interventions given difficulties around providing adequate primary care in remote settings. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Health promotion initiatives need to be prioritised to improve the health of Australian Indigenous people in the Pilbara and the initiatives should be delivered with the involvement of the local communities. Innovative solutions are required to improve the continuity of healthcare in the Pilbara, including increased use of mobile services.

Vibrio choleraeO1 in 2 Coastal Villages, Papua New Guinea

<i>Vibrio cholerae</i>O1 in 2 Coastal Villages, Papua New Guinea

Feasibility of a telemedicine ‘booth’ for supporting remote care in Scotland

Access to health care in remote settings is becoming increasingly difficult in Scotland. We have investigated the feasibility of a telemedicine 'booth'. Two telemedicine booths were constructed for display at the Royal Highland Show in Edinburgh. One was equipped for patient use and one for the doctor. The booths contained videoconferencing and physiological monitoring equipment connected via an IP link at a bandwidth of 1.1 Mbit/s. The picture resolution was 4CIF (704 x 576 pixels). A total of 238 members of the public used the booth for a teleconsultation with a doctor. Ninety-three percent completed questionnaires. Of the 221 respondents, 75% saw the booth as an opportunity to access specialist advice; 84% felt that the booth would save them attending a hospital or clinic; 60% felt that it would improve the way they looked after their own health. The concept of a telemedicine booth appears both feasible and acceptable to the public.