Detection of high-risk pregnancies in low-resource settings: a case study in Guatemala.

BACKGROUND: Maternal and neonatal mortality is still very high at a global level, even though its reduction is a goal established among the Sustainable Development Goals by the United Nations. In order to improve prenatal care to address this challenge, this article proposes a strategy to detect and refer high risk pregnancies in rural setting through a portable ultrasound system combined with blood and urine strip tests. METHODS: The Healthy Pregnancy project was conceived as a single, explanatory and positivist case study, with a sample of ten thousand pregnant women attended by itinerant nurses of the Departments of Alta Verapaz and San Marcos. These nurses were trained and equipped with 31 portable ultrasound, and blood and urine tests to detect common obstetric pathology. Moreover, two obstetricians were responsible for remotely supervising the quality of prenatal care. Target communities were selected by the Health Directorates of the public health system from those that had the highest maternal mortality in previous years. RESULTS: The project attended to 10,108 women in 2 years and 3 months. 55 twin gestations (0.54%) were diagnosed. Non-cephalic presentation was found in 14.87% of the pregnant women attended from week 32 onwards. 20 patients were referred for non-evolutive gestation. An 11.08% prevalence of anemia was detected. Urine infections were diagnosed in 16.43% of the cases. Proteinuria was detected in 2.6% of patients, but only 17 of them presented high blood pressure and were therefore referred with a suspected pre-eclampsia. DISCUSSION: The results obtained indicate that an intervention of these characteristics makes it possible to improve the quality of care of rural pregnant women in low and middle-income countries. CONCLUSION: The results show that with suitable equipment, training, and supervision, the nursing staff in charge of care in rural areas can identify and refer most of the obstetric risks in time, which may contribute to the reduction of maternal mortality. TRIAL REGISTRATION: This research was not registered because it is a case study in which the assignment of the medical intervention was not at the discretion of the investigators.

A Flexible 12-Lead/Holter Device with Compression Capabilities for Low-Bandwidth Mobile-ECG Telemedicine Applications.

In recent years, a number of proposals for electrocardiogram (ECG) monitoring based on mobile systems have been delivered. We propose here an STM32F-microcontroller-based ECG mobile system providing both long-term (several weeks) Holter monitoring and 12-lead ECG recording, according to the clinical standard requirements for these kinds of recordings, which in addition can yield further digital compression at stages close to the acquisition. The system can be especially useful in rural areas of developing countries, where the lack of specialized medical personnel justifies the introduction of telecardiology services, and the limitations of coverage and bandwidth of cellular networks require the use of efficient signal compression systems. The prototype was implemented using a small architecture, with a 16-bits-per-sample resolution. We also used a low-noise instrumentation amplifier TI ADS1198, which has a multiplexer and an analog-to-digital converter (16 bits and 8 channels) connected to the STM32F processor, the architecture of which incorporates a digital signal processing unit and a floating-point unit. On the one hand, the system portability allows the user to take the prototype in her/his pocket and to perform an ECG examination, either in 12-lead controlled conditions or in Holter monitoring, according to the required clinical scenario. An app in the smartphone is responsible for giving the users a friendly interface to set up the system. On the other hand, electronic health recording of the patients are registered in a web application, which in turn allows them to connect to the Internet from their cellphones, and the ECG signals are then sent though a web server for subsequent and ubiquitous analysis by doctors at any convenient terminal device. In order to determine the quality of the received signals, system testing was performed in the three following scenarios: (1) The prototype was connected to the patient and the signals were subsequently stored; (2) the prototype was connected to the patient and the data were subsequently transferred to the cellphone; (3) the prototype was connected to the patient, and the data were transferred to the cellphone and to the web via the Internet. An additional benchmarking test with expert clinicians showed the clinical quality provided by the system. The proposed ECG system is the first step and paves the way toward mobile cardiac monitors in terms of compatibility with the electrocardiographic practice, including the long-term monitoring, the usability with 12 leads, and the possibility of incorporating signal compression at the early stages of the ECG acquisition.

Use of a portable system with ultrasound and blood tests to improve prenatal controls in rural Guatemala.

BACKGROUND: Maternal and neonatal mortality figures remain unacceptably high worldwide and new approaches are required to address this problem. This paper evaluates the impact on maternal and neonatal mortality of a pregnancy care package for rural areas of developing countries with portable ultrasound and blood/urine tests. METHODS: An observational study was conducted, with intervention and control groups not randomly assigned. SETTING: Rural areas of the districts of Senahu, Campur and Carcha, in Alta Verapaz Department (Guatemala). The control group is composed by 747 pregnant women attended by the community facilitator, which is the common practice in rural Guatemala. The intervention group is composed by 762 pregnant women attended under the innovative Healthy Pregnancy project. That project strengthens the local prenatal care program, providing local nurses training, portable ultrasound equipment and blood and urine tests. The information of each pregnancy is registered in a medical exchange tool, and is later reviewed by a gynecology specialist to ensure a correct diagnosis and improve nurses training. RESULTS: No maternal deaths were reported within the intervention group, versus five cases in the control group. Regarding neonatal deaths, official data revealed a 64 % reduction for neonatal mortality. A 37 % prevalence of anemia was detected. Non-urgent referral was recommended to 70 pregnancies, being fetal malpresentation the main reported cause. CONCLUSION: Impact data on maternal mortality (reduction to zero) and neonatal mortality (NMR was reduced to 36 %) are encouraging, although we are aware of the limitations of the study related to possible biasing and the small sample size. The major reduction of maternal and neonatal mortality provides promising prospects for these low-cost diagnostic procedures, which allow to provide high quality prenatal care in isolated rural communities of developing countries. TRIAL REGISTRATION: This research was not registered because it is an observational study where the assignment of the medical intervention was not at the discretion of the investigators.

Design of New Procedures for Diagnosing Prevalent Diseases Using a Low-Cost Telemicroscopy System.

BACKGROUND: Currently, the diagnosis of prevalent diseases such as malaria, tuberculosis, or diarrheal diseases in rural areas of developing countries requires the displacement of the patient from their community health post to their reference health center or to ship a sample. This delays diagnosis and the treatment of disease. OBJECTIVE: Conduct research to develop a new method for rapid low-cost diagnosis of prevalent diseases in rural areas of developing countries (malaria, tuberculosis, parasitic infections, vaginal infections, and cervical cancer). METHODS: The study was divided into three phases. The first related to the drafting and validating of new protocols for the preparation of samples that should be adapted to be carried out in areas without power and with little trained personnel. The second phase consisted of developing a telemicroscopy system looking for low cost, software compatibility, and technical quality. Finally, the third phase evaluated the system as a diagnostic tool using direct observation with a conventional microscope as the gold standard. RESULTS: The validation of the new protocols showed that 100% of the vaginal swabs were processed correctly when using direct smear, while they were only 86.3% correct when using Gram stain; 68.3% of fecal samples were correctly processed using Kinyoun stain; 61.7% of blood samples when using thin film; and 83.8% when using thick film. Phase 2 permitted the development of a low-cost (<$250) and low-power (<15 W) telemicroscopy system that allows real-time consultation between health technicians and specialists. Finally, phase 3 proved that there was no difference between the diagnostics obtained by direct observation in a microscope and those ones obtained through the new telemicroscopy system. CONCLUSIONS: This study has verified the effectiveness of the telemicroscopy system as a diagnostic tool, given the complete agreement between the diagnoses made with it and those made with the gold standard.

TulaSalud: An m-health system for maternal and infant mortality reduction in Guatemala.

The Guatemalan NGO (Non-Governmental Organization) TulaSalud has implemented an m-health project in the Department of Alta Verapaz. This Department has 1.2 million inhabitants (78% living in rural areas and 89% from indigenous communities) and in 2012, had a maternal mortality rate of 273 for every 100,000 live births. This m-health initiative is based on the provision of a cell phone to community facilitators (CFs). The CFs are volunteers in rural communities who perform health prevention, promotion and care. Thanks to the cell phone, the CFs have become tele-CFs who able to carry out consultations when they have questions; send full epidemiological and clinical information related to the cases they attend to; receive continuous training; and perform activities for the prevention and promotion of community health through distance learning sessions in the Q'eqchí and/or Poqomchi' languages. In this study, rural populations served by tele-CFs were selected as the intervention group while the control group was composed of the rural population served by CFs without Information and Communication Technology (ICT) tools. As well as the achievement of important process results (116,275 medical consultations, monitoring of 6,783 pregnant women, and coordination of 2,014 emergency transfers), the project has demonstrated a statistically significant decrease in maternal mortality (p < 0.05) and in child mortality (p = 0.054) in the intervention group compared with rates in the control group. As a result of the telemedicine initiative, the intervention areas, which were selected for their high maternal and infant mortality rates, currently show maternal and child mortality indicators that are not only lower than the indicators in the control area, but also lower than the provincial average (which includes urban areas).

Telemedicine Networks of EHAS Foundation in Latin America.

Rural areas in developing countries are characterized by lack of resources, low population density, and scarcity of communications infrastructure. These circumstances make it difficult to provide appropriate health-care services. This paper explains research results achieved by Enlace Hispano Americano de Salud - Hispano American Health Link (EHAS) and how they have contributed to improve healthcare in isolated areas of developing countries through the use of information and communication technologies (ICT). As the first step, EHAS always collaborates with public health systems to identify its communication and information needs. Based on the analysis of needs, EHAS does research on appropriate technologies to provide communication in each context and on information systems suited to needs of health personnel. In parallel, EHAS has worked to provide applications that, making use of the communications services installed, could improve the health-care services in these remote areas. In this line, solutions to improve epidemiological surveillance or to provide telemedicine services (like a digital stethoscope or a tele-microscopy system) have been developed. EHAS has also performed several researches trying to ensure the sustainability of their solutions and has summarized them in a Management Framework for Sustainable e-Healthcare Provision. Finally, the effort to spread acquired knowledge has crystallized in a book that details all the technologies and procedures previously mentioned.

An open real-time tele-stethoscopy system.

BACKGROUND: Acute respiratory infections are the leading cause of childhood mortality. The lack of physicians in rural areas of developing countries makes difficult their correct diagnosis and treatment. The staff of rural health facilities (health-care technicians) may not be qualified to distinguish respiratory diseases by auscultation. For this reason, the goal of this project is the development of a tele-stethoscopy system that allows a physician to receive real-time cardio-respiratory sounds from a remote auscultation, as well as video images showing where the technician is placing the stethoscope on the patient's body. METHODS: A real-time wireless stethoscopy system was designed. The initial requirements were: 1) The system must send audio and video synchronously over IP networks, not requiring an Internet connection; 2) It must preserve the quality of cardiorespiratory sounds, allowing to adapt the binaural pieces and the chestpiece of standard stethoscopes, and; 3) Cardiorespiratory sounds should be recordable at both sides of the communication. In order to verify the diagnostic capacity of the system, a clinical validation with eight specialists has been designed. In a preliminary test, twelve patients have been auscultated by all the physicians using the tele-stethoscopy system, versus a local auscultation using traditional stethoscope. The system must allow listen the cardiac (systolic and diastolic murmurs, gallop sound, arrhythmias) and respiratory (rhonchi, rales and crepitations, wheeze, diminished and bronchial breath sounds, pleural friction rub) sounds. RESULTS: The design, development and initial validation of the real-time wireless tele-stethoscopy system are described in detail. The system was conceived from scratch as open-source, low-cost and designed in such a way that many universities and small local companies in developing countries may manufacture it. Only free open-source software has been used in order to minimize manufacturing costs and look for alliances to support its improvement and adaptation. The microcontroller firmware code, the computer software code and the PCB schematics are available for free download in a subversion repository hosted in SourceForge. CONCLUSIONS: It has been shown that real-time tele-stethoscopy, together with a videoconference system that allows a remote specialist to oversee the auscultation, may be a very helpful tool in rural areas of developing countries.

Impact of image spatial, temporal, and velocity resolutions on cardiovascular indices derived from color-Doppler echocardiography.

Quantitative processing of color-Doppler echocardiographic images has substantially improved noninvasive assessment of cardiac physiology. Many indices are computed from the velocity fields derived either from color-Doppler tissue imaging (DTI), such as acceleration, strain and strain-rate, or from blood-flow color-Doppler, such as intracardiac pressure gradients (ICPG). All of these indices are dependent on the finite resolution of the ultrasound scanner. Therefore, we developed an image-dependent method for assessing the influence of temporal, spatial, and velocity resolutions, on cardiovascular parameters derived from velocity images. In order to focus our study on the spatial, temporal, and velocity resolutions of the digital image, we did not consider the effect of other sources of noise such as the interaction between ultrasound and tissue. A simple first-order Taylor's expansion was used to establish the functional relationship between the acquired image velocity and the calculated cardiac index. Resolutions were studied on: (a) myocardial acceleration, strain, and strain-rate from DTI, and (b) ICPG from blood-flow color-Doppler. The performance of Taylor's-based error bounds (TBEB) was demonstrated on simulated models and illustrated on clinical images. Velocity and temporal resolution were highly relevant for the accuracy of DTI-derived parameters and ICPGs. TBEB allow to assess the effects of ideal digital image resolution on quantitative cardiovascular indices derived from velocity measurements obtained by cardiac imaging techniques.