Turning a blind eye: the mobilization of radiology services in resource-poor regions

Point-of-care ultrasound to inform antiviral treatment initiation in chronic hepatitis B virus infection in low-resource settings - the PUSH protocol

BACKGROUND

Chronic Hepatitis B (CHB) is prevalent worldwide and most related deaths occur in low-resource settings. Antiviral treatment of CHB is indicated in those with significant liver disease and markers of viral replication. However, recommended diagnostics such as elastography (a non-invasive imaging measure of fibrosis/cirrhosis) or HBV viral load are often lacking in these settings, which creates barriers to treatment. Point-of-care clinical B-mode ultrasound (US) has potential to overcome implementation barriers in HBV care programs in low-resource settings.

METHODS

We describe a Point-of-care US protocol for Hepatitis ("PUSH") to check for signs of cirrhosis and hepatocellular carcinoma in the liver of people with CHB. We performed a prospective observational study applying the protocol, first by trainee clinicians and then by trainers, in consecutive patients referred to our clinic for CHB treatment eligibility assessment. All patients additionally underwent physical examination, liver function tests (LFTs) and platelet counts. We describe the PUSH training approach and performance of the protocol.

RESULTS

Four clinicians and 111 adult patients with HBV infection were included in the development of PUSH. Using US, liver complications of HBV were documented in 31 (27.9%) patients; including cirrhosis in 15 patients, HCC with cirrhosis in 13, and HCC without cirrhosis in 3. Patients with sonographic findings had significantly more clinical symptoms also their LFTs were higher and more frequently indicative for HBV treatment. Of 28 patients with sonographic diagnosis of cirrhosis, 23 (82.1%) showed a nodular liver surface, 24 (85.7%) a coarse echotexture, 20 (71.4%) scarce vessels, and 9 (32.1%) an enlarged caudate lobe. Overall concordance of the findings between assessment of trainees and experienced sonographers was high, ranging from 90 to 95%; trainees were not blinded to clinical and laboratory findings.

CONCLUSION

Ultrasound can facilitate same-day initiation of antiviral therapy for chronic HBV monoinfection in a resource-limited setting and a streamlined protocol-driven liver ultrasound can be feasibly used by front line clinicians managing HBV.

Point-of-care ultrasound for tuberculosis and HIV-revisiting the focused assessment with sonography for HIV-associated tuberculosis (FASH) protocol and its differential diagnoses

BACKGROUND

The 'Focused assessment with sonography for HIV-associated tuberculosis' (FASH) protocol has been applied and researched for over a decade in HIV-infected patients with suspected extra-pulmonary tuberculosis. Interpretation of target FASH features may be challenging as they can also indicate alternative opportunistic diseases.

OBJECTIVES

The primary aim of the review was summarizing the accumulated evidence on the diagnostic accuracy of the FASH protocol including description of diagnoses of target FASH features.

SOURCES

Literature was searched using PubMed, Google Scholar, and publications referencing the original FASH publications; data from identified studies were compiled with data from studies identified by a preceding Cochrane review. A meta-analysis was performed based on a generalized linearized mixed model. Data on differential diagnoses were compiled by literature review and retrospective evaluation of clinical data.

CONTENT

We identified ten studies; abdominal target FASH features were most studied. Sensitivity and specificity estimates were 39% (95% CI 25-54) and 89% (95% CI 83-96) for enlarged lymph nodes (ten studies), and 30% (95% CI 16-45%) and 93% (95% CI 89-98%) for hypoechoic spleen lesions (eight studies). In people living with HIV differential diagnoses of target FASH features are multiple and primarily include other opportunistic infections and malignancies such as non-tuberculous mycobacterial infection, bacillary angiomatosis, hepato-splenic brucellosis, meliodiosis, visceral leishmaniasis, invasive fungal infections, and lymphoma as well as Kaposi sarcoma. Ultrasound-guided diagnostic sampling may assist obtention of a definitive diagnosis.

IMPLICATIONS

On the basis of current evidence, although limited by methodology, and personal experience, we recommend basic ultrasound training, including the FASH protocol and ultrasound-guided diagnostic interventions, for all healthcare providers working with people living with HIV in resource-limited settings.

Baran T, O’Connell A, Parker K. Enhancing breast ultrasound segmentation through fine-tuning and optimization techniques: Sharp attention UNet

Segmentation of breast ultrasound images is a crucial and challenging task in computer-aided diagnosis systems. Accurately segmenting masses in benign and malignant cases and identifying regions with no mass is a primary objective in breast ultrasound image segmentation. Deep learning (DL) has emerged as a powerful tool in medical image segmentation, revolutionizing how medical professionals analyze and interpret complex imaging data. The UNet architecture is a highly regarded and widely used DL model in medical image segmentation. Its distinctive architectural design and exceptional performance have made it popular among researchers. With the increase in data and model complexity, optimization and fine-tuning models play a vital and more challenging role than before. This paper presents a comparative study evaluating the effect of image preprocessing and different optimization techniques and the importance of fine-tuning different UNet segmentation models for breast ultrasound images. Optimization and fine-tuning techniques have been applied to enhance the performance of UNet, Sharp UNet, and Attention UNet. Building upon this progress, we designed a novel approach by combining Sharp UNet and Attention UNet, known as Sharp Attention UNet. Our analysis yielded the following quantitative evaluation metrics for the Sharp Attention UNet: the Dice coefficient, specificity, sensitivity, and F1 score values obtained were 0.93, 0.99, 0.94, and 0.94, respectively. In addition, McNemar's statistical test was applied to assess significant differences between the approaches. Across a number of measures, our proposed model outperformed all other models, resulting in improved breast lesion segmentation.

Assessment of a Brief Standardized Obstetric Ultrasound Training Program for Individuals Without Prior Ultrasound Experience

ABSTRACT

Obstetric volume sweep imaging (OB VSI) is a simple set of transducer movements guided by external body landmarks that can be taught to ultrasound-naive non-experts. This approach can increase access to ultrasound in rural/low-resources settings lacking trained sonographers. This study presents and evaluates a training program for OB VSI. Six trainees without previous formal ultrasound experience received a training program on the OB VSI protocol containing focused didactics and supervised live hands-on ultrasound scanning practice. Trainees then independently performed 194 OB VSI examinations on pregnancies >14 weeks with known prenatal ultrasound abnormalities. Images were reviewed by maternal-fetal medicine specialists for the primary outcome (protocol deviation rates) and secondary outcomes (examination quality and image quality). Protocol deviation was present in 25.8% of cases, but only 7.7% of these errors affected the diagnostic potential of the ultrasound. Error rate differences between trainees ranged from 8.6% to 53.8% ( P < 0.0001). Image quality was excellent or acceptable in 88.2%, and 96.4% had image quality capable of yielding a diagnostic interpretation. The frequency of protocol deviations decreased over time in the majority of trainees, demonstrating retention of training program over time. This brief OB VSI training program for ultrasound-naive non-experts yielded operators capable of producing high-quality images capable of diagnostic interpretation after 3 hours of training. This training program could be adapted for use by local community members in low-resource/rural settings to increase access to obstetric ultrasound.

Medical imaging consultation practices and challenges at public hospitals in the Amhara regional state, Northwest Ethiopia: a descriptive phenomenological study

BACKGROUND

Medical imaging plays a vital role in the accurate diagnosis, treatment and outcome prediction of many diseases and injuries. However, in many African countries, deserving populations do not have access to the proper medical imaging specialists' services. As a result, clinicians continue to struggle to provide medical imaging via consultation. However, little is known about conventional referral consultation practices and their challenges. This study, therefore, aimed to explore the practice and challenges of medical imaging service consultation among health professionals and patients in the context of the Ethiopian public healthcare delivery system.

METHODS

Descriptive phenomenological study was employed to explore the practice of medical imaging service consultation among health professionals and patients in public hospitals of Amhara region from October 12, 2021 to December 29, 2021. Semi-structured interview guides were prepared separately for key-informant and in-depth interviews. A total of 21 participants (6 hospital managers, 4 medical directors, 4 department heads, 3 medical imaging coordinators and 4 patients) were selected using the maximum variation sampling technique. All interviews were audio-recorded, transcribed verbatim and subjected to inductive thematic analysis using Open Code 4.02 software.

RESULTS

Six major themes emerged following the thematic analysis: (1) medical image service delivery practices; (2) medical imaging consultation modalities; (3) benefits and drawbacks of the consultation modalities; (4) challenges; (5) challenge mitigation strategies; and (6) future recommendations. Image films, compact disks, and telegram apps were the consultation modalities used by the referring clinicians to send the medical images to radiologists. Frequent failure of imaging machines, delayed equipment maintenance, inadequate infrastructure, shortage of budget, lack of radiologists, and low-quality of printed image films were among the challenges influencing the medical imaging consultation service.

CONCLUSIONS

This research explored onsite and referral imaging consultation practices. However, there are many challenges encountered by the referring clinicians and the radiologists during the consultation process. These challenges could potentially affect clinicians' ability to provide timely diagnosis and treatment services which would ultimately affects patient health status and service delivery. Virtual consultation via teleradiology and enhancing clinicians' competence through long-term and short-term trainings are recommended to improve the referral consultation practice.

Enhancing Breast Ultrasound Segmentation through Fine-tuning and Optimization Techniques: Sharp Attention UNet

Segmentation of breast ultrasound images is a crucial and challenging task in computer-aided diagnosis systems. Accurately segmenting masses in benign and malignant cases and identifying regions with no mass is a primary objective in breast ultrasound image segmentation. Deep learning (DL) has emerged as a powerful tool in medical image segmentation, revolutionizing how medical professionals analyze and interpret complex imaging data. The UNet architecture is a highly regarded and widely used DL model in medical image segmentation. Its distinctive architectural design and exceptional performance have made it a popular choice among researchers in the medical image segmentation field. With the increase in data and model complexity, optimization and fine-tuning models play a vital and more challenging role than before. This paper presents a comparative study evaluating the effect of image preprocessing and different optimization techniques and the importance of fine-tuning different UNet segmentation models for breast ultrasound images. Optimization and fine-tuning techniques have been applied to enhance the performance of UNet, Sharp UNet, and Attention UNet. Building upon this progress, we designed a novel approach by combining Sharp UNet and Attention UNet, known as Sharp Attention UNet. Our analysis yielded the following quantitative evaluation metrics for the Sharp Attention UNet: the dice coefficient, specificity, sensitivity, and F1 score obtained values of 0.9283, 0.9936, 0.9426, and 0.9412, respectively. In addition, McNemar's statistical test was applied to assess significant differences between the approaches. Across a number of measures, our proposed model outperforms the earlier designed models and points towards improved breast lesion segmentation algorithms.

Diagnosis of Pregnancy Complications Using Blind Ultrasound Sweeps Performed by Individuals Without Prior Formal Ultrasound Training

OBJECTIVE

To estimate the diagnostic accuracy of blind ultrasound sweeps performed with a low-cost, portable ultrasound system by individuals with no prior formal ultrasound training to diagnose common pregnancy complications.

METHODS

This is a single-center, prospective cohort study conducted from October 2020 to January 2022 among people with second- and third-trimester pregnancies. Nonspecialists with no prior formal ultrasound training underwent a brief training on a simple eight-step approach to performing a limited obstetric ultrasound examination that uses blind sweeps of a portable ultrasound probe based on external body landmarks. The sweeps were interpreted by five blinded maternal-fetal medicine subspecialists. Sensitivity, specificity, and positive and negative predictive values for blinded ultrasound sweep identification of pregnancy complications (fetal malpresentation, multiple gestations, placenta previa, and abnormal amniotic fluid volume) were compared with a reference standard ultrasonogram as the primary analysis. Kappa for agreement was also assessed.

RESULTS

Trainees performed 194 blinded ultrasound examinations on 168 unique pregnant people (248 fetuses) at a mean of 28±5.85 weeks of gestation for a total of 1,552 blinded sweep cine clips. There were 49 ultrasonograms with normal results (control group) and 145 ultrasonograms with abnormal results with known pregnancy complications. In this cohort, the sensitivity for detecting a prespecified pregnancy complication was 91.7% (95% CI 87.2-96.2%) overall, with the highest detection rate for multiple gestations (100%, 95% CI 100-100%) and noncephalic presentation (91.8%, 95% CI 86.4-97.3%). There was high negative predictive value for placenta previa (96.1%, 95% CI 93.5-98.8%) and abnormal amniotic fluid volume (89.5%, 95% CI 85.3-93.6%). There was also substantial to perfect mean agreement for these same outcomes (range 87-99.6% agreement, Cohen κ range 0.59-0.91, P<.001 for all).

CONCLUSION

Blind ultrasound sweeps of the gravid abdomen guided by an eight-step protocol using only external anatomic landmarks and performed by previously untrained operators with a low-cost, portable, battery-powered device had excellent sensitivity and specificity for high-risk pregnancy complications such as malpresentation, placenta previa, multiple gestations, and abnormal amniotic fluid volume, similar to results of a diagnostic ultrasound examination using a trained ultrasonographer and standard-of-care ultrasound machine. This approach has the potential to improve access to obstetric ultrasonography globally.

Sustainable volume sweep imaging lung teleultrasound in Peru: Public health perspectives from a new frontier in expanding access to imaging

Background

Pulmonary disease is a common cause of morbidity and mortality, but the majority of the people in the world lack access to diagnostic imaging for its assessment. We conducted an implementation assessment of a potentially sustainable and cost-effective model for delivery of volume sweep imaging (VSI) lung teleultrasound in Peru. This model allows image acquisition by individuals without prior ultrasound experience after only a few hours of training.

Methods

Lung teleultrasound was implemented at 5 sites in rural Peru after a few hours of installation and staff training. Patients were offered free lung VSI teleultrasound examination for concerns of respiratory illness or research purposes. After ultrasound examination, patients were surveyed regarding their experience. Health staff and members of the implementation team also participated in separate interviews detailing their views of the teleultrasound system which were systematically analyzed for key themes.

Results

Patients and staff rated their experience with lung teleultrasound as overwhelmingly positive. The lung teleultrasound system was viewed as a potential way to improve access to imaging and the health of rural communities. Detailed interviews with the implementation team revealed obstacles to implementation important for consideration such as gaps in lung ultrasound understanding.

Conclusions

Lung VSI teleultrasound was successfully deployed to 5 health centers in rural Peru. Implementation assessment revealed enthusiasm for the system among members of the community along with important areas of consideration for future teleultrasound deployment. This system offers a potential means to increase access to imaging for pulmonary illness and improve the health of the global community.

Breast Ultrasound Volume Sweep Imaging: A New Horizon in Expanding Imaging Access for Breast Cancer Detection

OBJECTIVE

The majority of people in the world lack basic access to breast diagnostic imaging resulting in delay to diagnosis of breast cancer. In this study, we tested a volume sweep imaging (VSI) ultrasound protocol for evaluation of palpable breast lumps that can be performed by operators after minimal training without prior ultrasound experience as a means to increase accessibility to breast ultrasound.

METHODS

Medical students without prior ultrasound experience were trained for less than 2 hours on the VSI breast ultrasound protocol. Patients presenting with palpable breast lumps for standard of care ultrasound examination were scanned by a trained medical student with the VSI protocol using a Butterfly iQ handheld ultrasound probe. Video clips of the VSI scan imaging were later interpreted by an attending breast imager. Results of VSI scan interpretation were compared to the same-day standard of care ultrasound examination.

RESULTS

Medical students scanned 170 palpable lumps with the VSI protocol. There was 97% sensitivity and 100% specificity for a breast mass on VSI corresponding to 97.6% agreement with standard of care (Cohen's κ = 0.95, P < .0001). There was a detection rate of 100% for all cancer presenting as a sonographic mass. High agreement for mass characteristics between VSI and standard of care was observed, including 87% agreement on Breast Imaging-Reporting and Data System assessments (Cohen's κ = 0.82, P < .0001).

CONCLUSIONS

Breast ultrasound VSI for palpable lumps offers a promising means to increase access to diagnostic imaging in underserved areas. This approach could decrease delay to diagnosis for breast cancer, potentially improving morbidity and mortality.

Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi

OBJECTIVE

To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings.

METHODS

Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded.

RESULTS

In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%).

CONCLUSIONS

POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.

Low-field MRI: Clinical promise and challenges

Modern MRI scanners have trended toward higher field strengths to maximize signal and resolution while minimizing scan time. However, high-field devices remain expensive to install and operate, making them scarce outside of high-income countries and major population centers. Low-field strength scanners have drawn renewed academic, industry, and philanthropic interest due to advantages that could dramatically increase imaging access, including lower cost and portability. Nevertheless, low-field MRI still faces inherent limitations in image quality that come with decreased signal. In this article, we review advantages and disadvantages of low-field MRI scanners, describe hardware and software innovations that accentuate advantages and mitigate disadvantages, and consider clinical applications for a new generation of low-field devices. In our review, we explore how these devices are being or could be used for high acuity brain imaging, outpatient neuroimaging, MRI-guided procedures, pediatric imaging, and musculoskeletal imaging. Challenges for their successful clinical translation include selecting and validating appropriate use cases, integrating with standards of care in high resource settings, expanding options with actionable information in low resource settings, and facilitating health care providers and clinical practice in new ways. By embracing both the promise and challenges of low-field MRI, clinicians and researchers have an opportunity to transform medical care for patients around the world. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 6.

No sonographer, no radiologist: Assessing accuracy of artificial intelligence on breast ultrasound volume sweep imaging scans

Breast ultrasound provides a first-line evaluation for breast masses, but the majority of the world lacks access to any form of diagnostic imaging. In this pilot study, we assessed the combination of artificial intelligence (Samsung S-Detect for Breast) with volume sweep imaging (VSI) ultrasound scans to evaluate the possibility of inexpensive, fully automated breast ultrasound acquisition and preliminary interpretation without an experienced sonographer or radiologist. This study was conducted using examinations from a curated data set from a previously published clinical study of breast VSI. Examinations in this data set were obtained by medical students without prior ultrasound experience who performed VSI using a portable Butterfly iQ ultrasound probe. Standard of care ultrasound exams were performed concurrently by an experienced sonographer using a high-end ultrasound machine. Expert-selected VSI images and standard of care images were input into S-Detect which output mass features and classification as "possibly benign" and "possibly malignant." Subsequent comparison of the S-Detect VSI report was made between 1) the standard of care ultrasound report by an expert radiologist, 2) the standard of care ultrasound S-Detect report, 3) the VSI report by an expert radiologist, and 4) the pathological diagnosis. There were 115 masses analyzed by S-Detect from the curated data set. There was substantial agreement of the S-Detect interpretation of VSI among cancers, cysts, fibroadenomas, and lipomas to the expert standard of care ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), the standard of care ultrasound S-Detect interpretation (Cohen's κ = 0.79 (0.65-0.94 95% CI), p<0.0001), the expert VSI ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), and the pathological diagnosis (Cohen's κ = 0.80 (0.64-0.95 95% CI), p<0.0001). All pathologically proven cancers (n = 20) were designated as "possibly malignant" by S-Detect with a sensitivity of 100% and specificity of 86%. Integration of artificial intelligence and VSI could allow both acquisition and interpretation of ultrasound images without a sonographer and radiologist. This approach holds potential for increasing access to ultrasound imaging and therefore improving outcomes related to breast cancer in low- and middle- income countries.

Regional Differences in Admissions and Treatment Outcomes for Hepatocellular Carcinoma Patients in Thailand

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the commonest cancers in Thailand. We report the stage and survival of patients who were admitted under the public universal health fund (NHSO) covering 47 million people to determine if there were regional disparities in the treatment outcomes in the country.

METHOD

We used the 2009-2013 Nationwide Hospital Admission Data, Thailand. Patients with hepatocellular carcinoma (HCC) were identified by the ICD10 code C22.0. Procedures were identified by ICD9-CM codes, and deaths were confirmed from the NHSO database and the national citizen registry. Thailand is divided into 6 regions and Bangkok. Hospitals were identified according to their specific reimbursement codes. Survival time started from the day of first admission and was estimated using the Kaplan-Meier method. The statistical method used to compare regions was Chi-squared tests (Pearson, likelihood ratio, linear-by linear association and Mantel-cox).

RESULTS

There were 36,956 HCC patients admitted during the study period. The overall median survival was 36 days. 1.63% of the patients had surgery, 0.96% had radiofrequency ablation (RFA), and 5.24% had trans-arterial chemoembolization (TACE). 90.24% did not have any tumor-specific therapy. The proportion of patients admitted for tumor-specific therapy vs. no tumor-specific therapy was significantly different between regions in all treatment modalities (p<0.01). Each treatment modality showed a wide range of median survival values across the regions (p<0.01). The best survival was seen in Bangkok, the South and the North (for surgery, RFA and TACE) and was often more than twice as long as the regions with the lowest survival, Central, East and West.

CONCLUSIONS

There was a large previously-unreported disparity in admissions and outcomes in Thailand for different treatment modalities for HCC. Bangkok and the South had the best treatment outcomes and often had median survivals more than twice as long as those in the West and East. Public policy to reduce this disparity will need to be implemented in the future.

Effect of Point-of-Care Ultrasound on Clinical Outcomes in Low-Resource Settings: A Systematic Review

Despite the potential for improved patient care, little is known of the true effect of point-of-care ultrasound (POCUS) on patient outcomes in resource-limited settings. Electronic databases were searched using medical subject heading and free text terms related to POCUS and resource-limited settings through August 2020. Two authors independently selected studies, assessed methodological quality using the Downs and Black scale and extracted data. Twenty observational studies were included in the final review. All studies had moderate to high risk of bias. No studies exhibited an effect on the pre-specified primary outcome of mortality. Varying degrees of change in differential diagnosis and management were reported, but definitions varied widely among studies. Estimates for change in diagnosis as a result of POCUS ranged from 15% to 52%, and those for change in management, from 17% to 87%. Articles on POCUS clinical utility represent a small part (4.6%) of the scholastic literature dedicated to POCUS in low-resource settings. POCUS is a valuable intervention to consider in resource-limited settings, with the potential to change diagnosis and patient management. The exact magnitude of effect remains unknown. There is a continued need for large-scale experimental studies to investigate the effect of POCUS on patient diagnosis, management and mortality.

Sensitivity of portable low-field magnetic resonance imaging for multiple sclerosis lesions

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Paired, same-day, 3T and 64mT MRI studies were analyzed in 33 MS patients.

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64mT MRI showed 94% sensitivity for detecting any lesions in 3T confirmed cases.

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The diameter of the smallest detected lesion was larger at 64mT compared to 3T.

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Total lesion volume estimates were strongly correlated between 3T and 64mT scans.

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Portable low-field MRI detects white matter lesions, but smaller lesions may be missed.

Magnetic resonance imaging (MRI) is a fundamental tool in the diagnosis and management of neurological diseases such as multiple sclerosis (MS). New portable, low-field strength, MRI scanners could potentially lower financial and technical barriers to neuroimaging and reach underserved or disabled populations, but the sensitivity of these devices for MS lesions is unknown. We sought to determine if white matter lesions can be detected on a portable 64mT scanner, compare automated lesion segmentations and total lesion volume between paired 3T and 64mT scans, identify features that contribute to lesion detection accuracy, and explore super-resolution imaging at low-field. In this prospective, cross-sectional study, same-day brain MRI (FLAIR, T1w, and T2w) scans were collected from 36 adults (32 women; mean age, 50 ± 14 years) with known or suspected MS using Siemens 3T (FLAIR: 1 mm isotropic, T1w: 1 mm isotropic, and T2w: 0.34–0.5 × 0.34–0.5 × 3–5 mm) and Hyperfine 64mT (FLAIR: 1.6 × 1.6 × 5 mm, T1w: 1.5 × 1.5 × 5 mm, and T2w: 1.5 × 1.5 × 5 mm) scanners at two centers. Images were reviewed by neuroradiologists. MS lesions were measured manually and segmented using an automated algorithm. Statistical analyses assessed accuracy and variability of segmentations across scanners and systematic scanner biases in automated volumetric measurements. Lesions were identified on 64mT scans in 94% (31/33) of patients with confirmed MS. The average smallest lesions manually detected were 5.7 ± 1.3 mm in maximum diameter at 64mT vs 2.1 ± 0.6 mm at 3T, approaching the spatial resolution of the respective scanner sequences (3T: 1 mm, 64mT: 5 mm slice thickness). Automated lesion volume estimates were highly correlated between 3T and 64mT scans (r = 0.89, p < 0.001). Bland-Altman analysis identified bias in 64mT segmentations (mean = 1.6 ml, standard error = 5.2 ml, limits of agreement = –19.0–15.9 ml), which over-estimated low lesion volume and under-estimated high volume (r = 0.74, p < 0.001). Visual inspection revealed over-segmentation was driven venous hyperintensities on 64mT T2-FLAIR. Lesion size drove segmentation accuracy, with 93% of lesions > 1.0 ml and all lesions > 1.5 ml being detected. Using multi-acquisition volume averaging, we were able to generate 1.6 mm isotropic images on the 64mT device. Overall, our results demonstrate that in established MS, a portable 64mT MRI scanner can identify white matter lesions, and that automated estimates of total lesion volume correlate with measurements from 3T scans.

Protocol for a Delphi Consensus Study to Determine the Essential and Optional Ultrasound Skills for Medical Practitioners Working in District Hospitals in South Africa

With increasing access to point of care ultrasound (POCUS) at district hospitals in South Africa, there is a lack of standardisation of skillsets among medical practitioners working at this level of care. This study protocol aims to use the Delphi process to achieve expert consensus on the essential and optional ultrasound skills required for medical practitioners working in district hospitals in South Africa. In alignment with the Delphi method, several iterative rounds will be implemented from June to November 2022. Purposive sampling will be conducted, through the recruitment of two representatives from each academic department of family medicine and two medical doctors working in district hospitals in each province in the country (N = 36). The POCUS skillsets published by the American Academy of Family Physicians will be circulated in the first iterative round, following which participants may suggest further additions. Once a consensus target of 70% has been achieved, the Delphi process will be finalised. The Delphi process and data analysis will be facilitated by an online Delphi platform. Findings from the study will provide insight into the design of the curriculum for POCUS training for medical practitioners in district hospitals and registrars in family medicine departments across the country.

Radiology for Thoracic Conditions in Low- and Middle-Income Countries

With a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases (CRDs) in low and middle-income countries (LMICs), access to radiological services is of critical importance for screening, diagnosis, and treatment guidance.

Accuracy of the Traditional COVID-19 Phone Triaging System and Phone Triage-Driven Deep Learning Model

Objectives:

During the COVID-19 pandemic, a quick and reliable phone-triage system is critical for early care and efficient distribution of hospital resources. The study aimed to assess the accuracy of the traditional phone-triage system and phone triage-driven deep learning model in the prediction of positive COVID-19 patients.

Setting:

This is a retrospective study conducted at the family medicine department, Cairo University.

Methods:

The study included a dataset of 943 suspected COVID-19 patients from the phone triage during the first wave of the pandemic. The accuracy of the phone triaging system was assessed. PCR-dependent and phone triage-driven deep learning model for automated classifications of natural human responses was conducted.

Results:

Based on the RT-PCR results, we found that myalgia, fever, and contact with a case with respiratory symptoms had the highest sensitivity among the symptoms/ risk factors that were asked during the phone calls (86.3%, 77.5%, and 75.1%, respectively). While immunodeficiency, smoking, and loss of smell or taste had the highest specificity (96.9%, 83.6%, and 74.0%, respectively). The positive predictive value (PPV) of phone triage was 48.4%. The classification accuracy achieved by the deep learning model was 66%, while the PPV was 70.5%.

Conclusion:

Phone triage and deep learning models are feasible and convenient tools for screening COVID-19 patients. Using the deep learning models for symptoms screening will help to provide the proper medical care as early as possible for those at a higher risk of developing severe illness paving the way for a more efficient allocation of the scanty health resources.

Trends in public sector radiological usage in the Western Cape Province, South Africa: 2009-2019

Background

Although global use of medical imaging has increased significantly, little is known about utilisation trends in low- and middle-income countries (LMICs).

Objectives

To evaluate changes over a decade in public sector diagnostic imaging utilisation at provincial level in a middle-income country.

Method

A retrospective analysis of medical imaging utilisation in the Western Cape Province of South Africa in 2009 and 2019. Use of conventional radiography, ultrasonography (US), fluoroscopy, CT, MRI, digital subtraction angiography (DSA) and whole-body digital radiography was assessed by total studies and studies/10³ people, for the whole province, the rural and metropolitan areas. Mammography utilisation was calculated for every 10³ females aged 40–70 years.

Results

The provincial population and total imaging investigations increased by 25% and 32%, respectively, whilst studies/10³ people increased by 5.5% (256 vs 270/10³), with marked variation by modality. Provincial US, CT and MRI utilisation/10³ people increased by 111% (20 vs 43/10³), 78% (10 vs 18/10³) and 32% (1.9 vs 2.5/10³) respectively, whilst use of fluoroscopy (3.6 vs 3.7/10³) and mammography (14.2 vs 15.9/10³ women aged 40–70 years) was steady and plain radiography decreased by 20% (216 vs 196/10³). For CT, mammography and fluoroscopy, percentage utilisation increases/10³ people were higher in the rural than metropolitan areas.

Conclusion

Population growth is the main driver of overall imaging utilisation in our setting. The relatively constant imaging workload per 1000 people, albeit with increasing ultrasound, CT and MR utilisation, and decreasing use of plain radiography, reflects improved provincial imaging infrastructure, and appropriate use of available resources.

Analysis of registered radiological equipment in Kenya

INTRODUCTION

diagnostic radiology plays a key role in healthcare. Proper planning of healthcare requires accurate and robust data. There´s, however, paucity of comprehensive figures on radiological equipment in the African setting. The goal of this study was to carry out an in-depth analysis of the registered radiological equipment in Kenya, a lower middle-income African country, and compare the findings to published international data.

METHODS

data on radiological equipment were obtained from the Kenya Nuclear Regulatory Authority and analyzed as units/million of the population by imaging modality, health service sector and administrative units. The findings were then compared to published international data.

RESULTS

there has been an overall increase in the number of radiological equipment in comparison to data published in 2013, with a relatively uniform distribution of resources across all eight regions. General radiography is the most available modality at 24.5 units/million with the majority of the equipment owned privately, while the public sector (9.6 units/million) has less than a half of the WHO recommendation of 20 units/million. Accessibility to computerized tomography (CT) scan, fluoroscopy and mammography in the public sector closely mirrors that of South Africa. On the contrary, positron emission tomography-computerized tomography (PET-CT) is the least-resourced modality and is currently only available in the private sector.

CONCLUSION

the increased number and homogenous distribution of radiological resources can largely be attributed to the Managed Equipment Services project launched by the national government in 2016. More needs to be done with regards to availability of PET/CT scanners and general radiography equipment in the public sector.

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.

Simulated diagnostic performance of low-field MRI: Harnessing open-access datasets to evaluate novel devices

The purpose of this study is to demonstrate a method for virtually evaluating novel imaging devices using machine learning and open-access datasets, here applied to a new, low-field strength portable 64mT MRI device. Paired 3 T and 64mT brain images were used to develop and validate a transformation converting standard clinical images to low-field quality images. Separately, 3 T images were aggregated from open-source databases spanning four neuropathologies: low-grade glioma (LGG, N = 76), high-grade glioma (HGG, N = 259), stroke (N = 28), and multiple sclerosis (MS, N = 20). The transformation method was then applied to the open-source data to generate simulated low-field images for each pathology. Convolutional neural networks (DenseNet-121) were trained to detect pathology in axial slices from either 3 T or simulated 64 mT images, and their relative performance was compared to characterize the potential diagnostic capabilities of low-field imaging. Algorithm performance was measured using area under the receiver operating characteristic curve. Across all cohorts, pathology detection was similar between 3 T and simulated 64mT images (LGG: 0.97 vs. 0.98; HGG: 0.96 vs. 0.95; stroke: 0.94 vs. 0.94; MS: 0.90 vs 0.87). Pathology detection was further characterized as a function of lesion size, intensity, and contrast. Simulated images showed decreasing sensitivity for lesions smaller than 4 cm². While simulations cannot replace prospective trials during the evaluation of medical devices, they can provide guidance and justification for prospective studies. Simulated data derived from open-source imaging databases may facilitate testing and validation of new imaging devices.

Association between antenatal ultrasound findings and neonatal outcomes in rural Uganda: a secondary analysis

BACKGROUND

Although the use of prenatal ultrasound services has increased in low- income and lower middle-income countries, there has not been a concurrent improvement in perinatal mortality. It remains unknown whether individual ultrasound findings in this setting are associated with neonatal death or the need for resuscitation at delivery. If associations are identified by ultrasound, they could be used to inform the birth attendant and counsel the family regarding risk, potentially altering delivery preparedness in order to reduce neonatal mortality.

METHODS

This was a secondary analysis of data collected from a prospective cohort. Data was gathered at Nawanyago Health Centre III in Kamuli District, Uganda. Participants included pregnant women who received second and third trimester prenatal ultrasound scans and delivered at that center between July 2010 and August 2018. All ultrasounds were performed at Nawanyago and deliveries were attended solely by midwives or nurses. Predictor variables included the following ultrasound findings: fetal number, fetal presentation, and amniotic fluid volume. The primary outcome was bag-mask ventilation (BMV) of the neonate at delivery. The secondary outcome was stillbirth or neonatal death in the delivery room.

RESULTS

Primary outcome data was available for 1105 infants and secondary outcome data was available for 1098 infants. A total of 33 infants received BMV at delivery. The odds of receiving BMV at delivery was significantly increased if amniotic fluid volume was abnormal (OR 4.2, CI 1.2-14.9) and there were increased odds for multiple gestation (OR 1.9, CI 0.7-5.4) and for non-vertex fetal presentation (OR 1.4, CI 0.6-3.2) that were not statistically significant. Stillbirth or neonatal death in the delivery room was diagnosed for 20 infants. Multiple gestation (OR 4.7, CI 1.6-14.2) and abnormal amniotic fluid volume (OR 4.8, CI 1.0-22.1) increased the odds of stillbirth or neonatal death in the delivery room, though only multiple gestation was statistically significant.

CONCLUSION

Common findings that are easily identifiable on ultrasound in low- and lower middle-income countries are associated with adverse perinatal outcomes. Education could lead to improved delivery preparedness, with the potential to reduce perinatal mortality. This was a preliminary study; larger prospective studies are needed to confirm these findings.

Towards equity: a retrospective analysis of public sector radiological resources and utilization patterns in the metropolitan and rural areas of the Western Cape Province of South Africa in 2017

Background

The reduction of inequality is a key United Nations 2030 Sustainable Development Goal (WHO, Human Resources for Health: foundation for Universal Health Coverage and the post-2015 development agenda, 2014; Transforming our world: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform, 2020). Despite marked disparities in radiological services globally, particularly between metropolitan and rural populations in low- and middle-income countries, there has been little work on imaging resources and utilization patterns in any setting (Transforming our world: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform, 2020; WHO, Local Production and Technology Transfer to Increase Access to Medical Devices, 2019; European Society of Radiology (ESR), Insights Imaging 6:573-7, 2015; Maboreke et al., An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity, 2020; Kabongo et al., Pan Afr Med J 22, 2015; Skedgel et al., Med Decis Making 35:94-105, 2015; Mollura et al., J Am Coll Radiol 913-9, 2014; Culp et al., J Am Coll Radiol 12:475-80, 2015; Mbewe et al., An audit of licenced Zambian diagnostic imaging equipment and personnel, 2020). To achieve equity, a better understanding of the integral components of the so called “imaging enterprise” is important. The aim was to analyse a provincial radiological service in a middle-income country.

Methods

An institutional review board-approved retrospective audit of radiological data for the public healthcare sector of the Western Cape Province of South Africa for 2017, utilizing provincial databases.

We conducted population-based analyses of imaging equipment, personnel, and service utilization data for the whole province, the metropolitan and the rural areas.

Results

Metropolitan population density exceeds rural by a factor of ninety (1682 vs 19 people/km²). Rural imaging facilities by population are double the metropolitan (20 vs 11/10⁶ people). Metropolitan imaging personnel by population (112 vs 53/10⁶ people) and equipment unit (1.7 vs 0.7/unit) are more than double the rural. Overall population-based utilization of imaging services was 30% higher in the metropole (289 vs 214 studies/10³ people), with mammography (24 vs 5 studies/10³ woman > 40 years) and CT (21 vs 6/10³ people) recording the highest, and plain radiography (203 vs 171/10³ people) the lowest differences.

Conclusion

Despite attempts to achieve imaging equity through the provision of increased facilities/million people in the rural areas, differential utilization patterns persist.

The achievement of equity must be seen as a process involving incremental improvements and iterative analyses that define progress towards the goal.

Medical Imaging: The Missing Element of National Health Plans

Purpose: Radiology global outreach programs have increased in recent years but progressed more slowly than other specialties. Establishing radiology services is increasingly recognized as a priority in resource-limited settings. Myanmar has a tremendous disease burden that is treatable with interventional radiology (IR) techniques, and aims to grow and effectively integrate this service into its public healthcare sector. Through collaborations between Asia Pacific Society of Cardiovascular and Interventional Radiology (APSCVIR) and Myanmar Radiological Society (MRS), the field of IR has grown exponentially over recent years. This study aims to provide a Myanmar national IR report on the current trends and future challenges. Methods and materials: Descriptive variables across five domains (facility and equipment, workforce, supplies, infrastructure, and casemix) from the four public sector hospitals with IR capability were obtained between 2016-2019. The four hospitals were Yangon General Hospital (YGH), Yangon Specialty Hospital (YSH), Mandalay General Hospital (MGH), and Defense Services General Hospital (DSGH). Data were analyzed to demonstrate progress in IR and the differing casemix. Results: There are currently four IR-capable hospitals and nine interventional radiologists across Myanmar’s public healthcare sector. IR case volumes tripled from 514 cases in 2016 to more than 1,500 cases in 2019. The three most common procedures performed were trans-arterial chemoembolization (TACE, 63%), bronchial arterial embolization (BAE, 7.7%), and drainages (7.7%). Significant challenges to the growth and adoption of IR services span the domains of infrastructure, equipment and supplies, workforce, and IR awareness, among other clinical specialties. Conclusion: Myanmar’s healthcare priorities, coupled with international radiological outreach programs, have led to rapid growth of IR. The exponential growth in case volumes is promising for Myanmar and other developing countries. But to widen the scope of practice and integrate the service within local clinical workflows, a holistic effort that addresses multiple domains is needed in the future.

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.

Evaluation of Diagnostic Imaging Capacity and the Role for Point-of-Care Ultrasound (POCUS) within the Zanzibar Health System

Background: The Zanzibar Ministry of Health identified access to ultrasound (US) as a system priority due to limited diagnostic imaging capacity and consequent impact on patient care and requested a needs assessment in this regard. As a result, the objective of this study was to assess diagnostic imaging capacity focusing on ultrasound in Zanzibar, including health care providers’ (HCPs) current training, use, and barriers to implementation.  Methods: A previously published ultrasound needs assessment survey was modified and administered on-site at the eight public hospitals in Zanzibar among a convenience sample of HCPs. Demographics, perceived US needs, current training and practice, and availability of specialty support were assessed. HCPs also completed focused personal interviews (FPIs) to explore experience with training, interests, and barriers to ultrasound. On-site diagnostic imaging modalities were assessed.  Results: There were nine ultrasound machines present at six of the eight public hospitals assessed. All had x-ray, but only one had a CT scanner and a radiologist. There was no MRI capacity at the hospitals assessed at the time of the study. Survey data among 40 participants revealed that prior experience with POCUS was limited with only 10% reporting any prior ultrasound training or experience.  The majority of those surveyed (72%), indicated a ‘high’ interest in learning ultrasound.  Of those reporting interest in POCUS applications, obstetrics was the most often cited (70%). Lack of ultrasound machines (40%) and educators (28%) were identified as the greatest barriers. Conclusion: HCPs in Zanzibar have limited access to diagnostic imaging, including ultrasound, and expressed a high level of interest in learning point-of-care ultrasound. A shortage of machines and educators are the main barriers to widespread use. Obstetrics is the application for which ultrasound is currently most used and is the application HCPs are most interested in learning. Equipment and educational support for a POCUS program could improve care by increasing access to diagnostic imaging.

Pragmatic Recommendations for the Management of COVID-19 Patients with Shock in Low- and Middle-Income Countries

As some patients infected with the novel coronavirus progress to critical illness, a subset will eventually develop shock. High-quality data on management of these patients are scarce, and further investigation will provide valuable information in the context of the pandemic. A group of experts identify a set of pragmatic recommendations for the care of patients with SARS-CoV-2 and shock in resource-limited environments. We define shock as life-threatening circulatory failure that results in inadequate tissue perfusion and cellular dysoxia/hypoxia, and suggest that it can be operationalized via clinical observations. We suggest a thorough evaluation for other potential causes of shock and suggest against indiscriminate testing for coinfections. We suggest the use of the quick Sequential Organ Failure Assessment (qSOFA) as a simple bedside prognostic score for COVID-19 patients and point-of-care ultrasound (POCUS) to evaluate the etiology of shock. Regarding fluid therapy for the treatment of COVID-19 patients with shock in low-middle-income countries, we favor balanced crystalloids and recommend using a conservative fluid strategy for resuscitation. Where available and not prohibited by cost, we recommend using norepinephrine, given its safety profile. We favor avoiding the routine use of central venous or arterial catheters, where availability and costs are strong considerations. We also recommend using low-dose corticosteroids in patients with refractory shock. In addressing targets of resuscitation, we recommend the use of simple bedside parameters such as capillary refill time and suggest that POCUS be used to assess the need for further fluid resuscitation, if available.

Achieving universal access to obstetric ultrasound in resource constrained settings: A narrative review

OBJECTIVES

The potential benefits and challenges of achieving universal access to obstetric ultrasound services in resource constrained settings were reviewed, with a view to making some recommendations to address the huge burden of avoidable maternal and child morbidity and mortality.

KEY FINDINGS

In most resource-poor settings of the world, antenatal ultrasound is available only to a privileged few in urban centres, while the majority of the population living in rural areas have little or no access to diagnostic imaging services. There is also the extreme shortage of sonographers and doctors with specialist training in sonography. A comprehensive regulation must be put in place to achieve maximum benefits and to ensure quality assurance; appropriate use and application of ethics and training must be comprehensive.

CONCLUSION

Ultrasound service provision, in resource-scarce settings, has the potential to improve access and quality of health care services in areas like the point of care ultrasound service provision and in the fields of obstetrics and gynaecology. A comprehensive regulation must be put in place to achieve maximum benefits and to ensure quality assurance.

IMPLICATIONS FOR PRACTICE

Making ultrasound technology available and affordable in resource scare settings has the potential to improve access to diagnostic imaging services and reduce avoidable maternal and child death in resource constrained settings.

Artificial Intelligence for COVID-19: Rapid Review

BACKGROUND

COVID-19 was first discovered in December 2019 and has since evolved into a pandemic.

OBJECTIVE

To address this global health crisis, artificial intelligence (AI) has been deployed at various levels of the health care system. However, AI has both potential benefits and limitations. We therefore conducted a review of AI applications for COVID-19.

METHODS

We performed an extensive search of the PubMed and EMBASE databases for COVID-19-related English-language studies published between December 1, 2019, and March 31, 2020. We supplemented the database search with reference list checks. A thematic analysis and narrative review of AI applications for COVID-19 was conducted.

RESULTS

In total, 11 papers were included for review. AI was applied to COVID-19 in four areas: diagnosis, public health, clinical decision making, and therapeutics. We identified several limitations including insufficient data, omission of multimodal methods of AI-based assessment, delay in realization of benefits, poor internal/external validation, inability to be used by laypersons, inability to be used in resource-poor settings, presence of ethical pitfalls, and presence of legal barriers. AI could potentially be explored in four other areas: surveillance, combination with big data, operation of other core clinical services, and management of patients with COVID-19.

CONCLUSIONS

In view of the continuing increase in the number of cases, and given that multiple waves of infections may occur, there is a need for effective methods to help control the COVID-19 pandemic. Despite its shortcomings, AI holds the potential to greatly augment existing human efforts, which may otherwise be overwhelmed by high patient numbers.

Overcoming Challenges for Successful PACS Installation in Low-Resource Regions: Our Experience in Nigeria

In this paper, we walk you through our challenges, successes, and experience while participating in a Global Health Outreach Project at the University College Hospital (UCH) Ibadan, Nigeria. The scope of the project was to install a Picture Archive and Communication System (PACS) to establish a centralized viewing network at UCH's Radiology Department, for each of their digital modalities. Installing a PACS requires robust servers, the ability to retrieve and archive studies, ensuring workstations can view studies, and the configuration of imaging modalities to send studies. We anticipated that we might experience hurdles for each of these requirements, due to limited resources and without the availability to make a site visit prior to the start of the project. While we ultimately experienced delays and troubleshooting was required at each turn of the install, with the help of dedicated volunteers both on and off-site and the UCH staff, our shared goal was accomplished.

Point-of-care ultrasound in resource-limited settings: the PURLS fellowship

Background

The role of point-of-care ultrasonography (POCUS) is rapidly expanding in both resource-rich and resource-limited settings (RLS). One limitation to this rapid expansion has been the lack of educators adequately trained to teach this user-dependent skill. This is particularly true in RLS, where disease presentations, infrastructure limitations, and approach to medical education present unique challenges to the direct application of resource-rich emergency department POCUS curricula.

Objectives

We describe the point-of-care ultrasound in resource-limited settings (PURLS) fellowship, a novel curriculum designed to provide advanced training and expertise in clinical care and POCUS application and education in RLS.

Conclusion

Our curriculum design is one approach to create context-specific POCUS education for use in RLS, thereby improving patient care.

X-ray operators' self-perceived competence, barriers and facilitators in general radiography practice in Western Australia

INTRODUCTION

Australian X-ray operators (XROs) are health workers qualified with a limited radiography licence to perform basic radiography examinations in rural areas of Australia. However, no previous study explored Western Australian (WA) XROs' radiography practice. The purpose of this study was to investigate WA XROs' self-perceived competence in the general radiography practice, and barriers and facilitators to their competence for determination of appropriate strategies to improve quality and safety of the radiographic service provided by them.

METHODS

Institutional review board approval and informed consent from participants were obtained. Interviews were conducted with the WA XROs to obtain demographic information and identify their self-perceived competence in the general radiography practice, and the barriers and facilitators to their competence. A thematic analysis was used to analyse the interview data.

RESULTS

A total of nine interviews were conducted (eight nurses and one paramedic). Participants indicated that they felt highly competent in patient care in radiography and adequately competent in the production of diagnostically acceptable images. The self-perceived barriers include overload of responsibilities, a lack of continuing professional development, and inadequacy of communication, support and XRO courses. The facilitators, post-qualification/course training, support in undertaking examinations, primary professional roles and a small population of the rural and remote areas were identified.

CONCLUSION

Based on interview data from nine WA XROs, the perception is that they have competence adequate for providing an acceptable quality radiographic service.

IMPLICATIONS FOR PRACTICE

A continuous XRO course review, and provision of a video conference support channel, an online XRO networking forum and additional XROs and/or radiographers working with XROs undertaking the radiography examinations were perceived as the appropriate strategies to improve the WA XROs' radiography practice. However, these require financial and/or managerial support from governments.

Evaluation of a point-of-care ultrasound curriculum taught by medical students for physicians, nurses, and midwives in rural Indonesia

PURPOSE

In the Indonesian health-care system, nurses and midwives often serve as the primary health-care providers due to physician shortages. Seeking to address the need for medical care in resource-limited environments, some have advocated for portable equipment in the hands of health-care providers. We hypothesized that medical students are able to effectively teach point-of-care ultrasound (POCUS) to physicians, nurses, and midwives in rural Indonesia.

METHODS

We conducted a prospective, observational study using health-care practitioners from a clinic and accredited school for nursing and midwifery in Mojokerto, East Java, Indonesia. Enrolled practitioners took part in a 4-week POCUS course followed by postinstructional testing.

RESULTS

A total of 55 health-care practitioners completed the course. This included 19 physicians, 13 nurses, and 19 midwives. Of the 55 clinicians, 43 (72%) passed the course and 12 (28%) failed.

CONCLUSIONS

Physicians, nurses, and midwives in rural Indonesia showed significant acquisition of ultrasound (US) knowledge and skills following a 4-week US course. Following training, all three groups displayed skills in practical US use during a postcourse practical examination. This is one of the first studies to assess the efficacy of medical students teaching POCUS to midwives and nurses.

The impact of computed radiography and teleradiology on patients' diagnosis and treatment in Mweso, the Democratic Republic of Congo

INTRODUCTION

High quality diagnostic imaging can provide increased diagnostic accuracy and help guide medical decision-making and management, however challenges for radiology in resource-limited settings are numerous. Diagnostic imaging and teleradiology have financial and logistical implications, so evidence of impact is crucial. We sought to test the hypothesis that the implementation of computed radiography with teleradiology consultation support will significantly change diagnoses and treatment plans in a resource limited setting.

METHOD

Paired before-after study to determine the therapeutic impact of an add-on diagnostic test. 'Preliminary Plan' and 'Final Plan' forms allowed direct comparison of diagnosis and treatment plans at initial consultation and following radiography and teleradiology. Consecutive consenting patients were included until the sample size (600) was reached. Changes in both diagnosis and treatment plan were analysed in the whole cohort, with sub-analyses of children aged <5 years, and cases of chest radiography.

RESULTS

Final analysis included 536 cases. Diagnosis changed following radiography and teleradiology in 62% of cases, and treatment plans changed in 61%. In chest radiography cases, 70% of diagnoses and 62% of treatment plans changed, while in children <5 years 66% of diagnoses and 58% of treatment plans changed. Reduced final treatment plans were most common for exploratory surgery (72% decrease), surgical orthopaedic intervention (62% decrease), and TB treatment (52% decrease), allowing more conservative medical or surgical management in 61 cases. Increased final treatment plans were highest in the orthopaedic and interventional surgery and referral categories. Of 42 cases requiring interventional surgery in the final plan, 26 (62%) were identified only after radiography and teleradiology. 16 additional cases were indicated for orthopaedic surgery, 10 cases required patient transfer, and TB treatment was indicated in 45 cases. A change in the original prescription plan occurred in 41% of 536 cases, with one or more prescriptions stopped in 28% of all cases.

CONCLUSION

We found that computed radiography with teleradiology had significant clinical value in this resource-limited setting, with the potential to affect both patient outcomes and treatment costs through providing improved diagnostics and avoiding unnecessary treatments and medications.

Sound Around the World: Ultrasound for Tropical Diseases

Ultrasound for diagnosis and staging of schistosomiasis and echinococcosis have paved the way over the past several decades for the application of ultrasound in tropical diseases. Until recently, the size and cost of ultrasound systems limited the application in low-resource settings. The increase in portable ultrasound systems has given more clinicians access to ultrasound, and clinically based protocols for the care of patients have emerged, such as focused assessment with sonography for HIV/TB and tropical cardiac ultrasound. This article explores the history and current use of ultrasound in these diseases and highlights their application in the care of patients.

Stakeholder Perceptions of Point-of-Care Ultrasound Implementation in Resource-Limited Settings

Background: Nearly half of the world lacks access to diagnostic imaging. Point of care ultrasound (POCUS) is a versatile and relatively affordable imaging modality that offers promise as a means of bridging the radiology gap and improving care in low resource settings. Methods: We performed semi-structured interviews of key stakeholders at two diverse hospitals where POCUS implementation programs had recently been conducted: one in a rural private hospital in Haiti and the other in a public referral hospital in Malawi. Questions regarding the clinical utility of POCUS, as well as barriers and facilitators of its implementation, were asked of study participants. Using the Framework Method, analysis of interview transcripts was guided by the WHO ASSURED criteria for point of care diagnostics. Results: Fifteen stakeholders with diverse roles in POCUS implementation were interviewed. Interviewees from both sites considered POCUS a valuable diagnostic tool that improved clinical decisions. They perceived barriers to adequate training as one of the most important remaining barriers to POCUS implementation. Conclusions: In spite of the increasing affordability and portability of ultrasounds devices, there are still important barriers to the implementation of POCUS in resource-limited settings.

An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity

Introduction

Approximately two-thirds of the world's population has no access to diagnostic imaging. Basic radiological services should be integral to universal health coverage. The World Health Organization postulates that one basic X-ray and ultrasound unit for every 50000 people will meet 90% of global imaging needs. However, there are limited country-level data on radiological resources, and little appreciation of how such data reflect access and equity within a healthcare system. The aim of this study was a detailed analysis of licensed Zimbabwean radiological equipment resources.

Methods

The equipment database of the Radiation Protection Authority of Zimbabwe was interrogated. Resources were quantified as units/million people and compared by imaging modality, geographical region and healthcare sector. Zimbabwean resources were compared with published South African and Tanzanian data.

Results

Public-sector access to X-ray units (11/10⁶ people) is approximately half the WHO recommendation (20/10⁶ people), and there exists a 5-fold disparity between the least- and best-resourced regions. Private-sector exceeds public-sector access by 16-fold. More than half Zimbabwe's radiology equipment (215/380 units, 57%) is in two cities, serving one-fifth of the population. Almost two-thirds of all units (243/380, 64%) are in the private sector, routinely accessible by approximately 10% of the population. Southern African country-level public-sector imaging resources broadly reflect national per capita healthcare expenditure.

Conclusion

There exists an overall shortfall in basic radiological equipment resources in Zimbabwe, and inequitable distribution of existing resources. The national radiology equipment register can reflect access and equity in a healthcare system, while providing medium-term radiological planning data.

How Strongly Do Physical Examination Estimates and Ultrasonographic Measurements of Liver Size Correlate? A Prospective Study

BACKGROUND

Liver size assessed by physical examination and ultrasound has long been used to gain useful clinical information. The size measurements obtained by these modalities have been difficult to compare as they are measured in 2 different axes (transaxial vs midclavicular). Our objective was to identify a measurement correlation between ultrasound and physical examination liver size findings. We aimed to develop a correction factor whereby the liver size could be translated between the measured transaxial size obtained by ultrasound and physical examination size when measured in the midclavicular line.

METHODS

We conducted a prospective study including 101 adult patients with liver disease undergoing liver biopsy between April 2008 and November 2008 at Penn State Health Milton S Hershey Medical Center. Liver measurements were obtained by physical examination and ultrasound, which were performed by a single hepatologist.

RESULTS

The average physical examination size using the midclavicular approach was 8.9 cm ± 1.13. On ultrasound, the average transaxial measurement was 14.3 cm ± 1.6. A ratio was made between measurements from the midclavicular line physical examination size and transaxial ultrasound size, and found to have a mean correction factor of 1.6 ± 0.14. The correction factor was applied to the physical examination-determined liver size and compared with ultrasound findings, with 76% of values (77/101) falling within 10% of the ultrasound-determined liver size.

CONCLUSION

This study proves that a strong correlation exists between physical examination estimates of liver size and the measured size on ultrasonography. Multiplying the percussed liver span by a correction factor consistently yields accurate predictions of the transaxial liver span.

Acoustic Methods for Pulmonary Diagnosis

Recent developments in sensor technology and computational analysis methods enable new strategies to measure and interpret lung acoustic signals that originate internally, such as breathing or vocal sounds, or are externally introduced, such as in chest percussion or airway insonification. A better understanding of these sounds has resulted in a new instrumentation that allows for highly accurate as well as portable options for measurement in the hospital, in the clinic, and even at home. This review outlines the instrumentation for acoustic stimulation and measurement of the lungs. We first review the fundamentals of acoustic lung signals and the pathophysiology of the diseases that these signals are used to detect. Then, we focus on different methods of measuring and creating signals that have been used in recent research for pulmonary disease diagnosis. These new methods, combined with signal processing and modeling techniques, lead to a reduction in noise and allow improved feature extraction and signal classification. We conclude by presenting the results of human subject studies taking advantage of both the instrumentation and signal processing tools to accurately diagnose common lung diseases. This paper emphasizes the active areas of research within modern lung acoustics and encourages the standardization of future work in this field.

Improved Detection of Lung Fluid With Standardized Acoustic Stimulation of the Chest

Accumulation of excess air and water in the lungs leads to breakdown of respiratory function and is a common cause of patient hospitalization. Compact and non-invasive methods to detect the changes in lung fluid accumulation can allow physicians to assess patients’ respiratory conditions. In this paper, an acoustic transducer and a digital stethoscope system are proposed as a targeted solution for this clinical need. Alterations in the structure of the lungs lead to measurable changes which can be used to assess lung pathology. We standardize this procedure by sending a controlled signal through the lungs of six healthy subjects and six patients with lung disease. We extract mel-frequency cepstral coefficients and spectroid audio features, commonly used in classification for music retrieval, to characterize subjects as healthy or diseased. Using the \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$K$ \end{document}-nearest neighbors algorithm, we demonstrate 91.7% accuracy in distinguishing between healthy subjects and patients with lung pathology.

The implementation of a longitudinal POCUS curriculum for physicians working at rural outpatient clinics in Chiapas, Mexico

Background

Medical care in resource limited settings is challenging, particularly with limited access to diagnostic and imaging studies. The most portable and cost effective diagnostic imaging in these areas is ultrasound. Ultrasound is a very teachable skill with a short, single intensive training course and hands-on teaching; however, there are limited data on a longitudinal point-of-care ultrasound (POCUS) curriculum in resource limited settings. The goal of this intervention is to develop an effective longitudinal POCUS curriculum for local physicians working in rural clinics in the state of Chiapas, Mexico, and evaluate its effectiveness on patient care.

Methods

This is a 12-month longitudinal ultrasound educational curriculum for local supervising physicians working in rural clinics in Chiapas, Mexico. The 10 clinics are a collaboration of the Mexican government and Compañeros En Salud with limited access to any diagnostic imaging or laboratory studies. The investigators assisted in obtaining four portable ultrasound machines for use in the clinics. Next, they organized four point-of-care ultrasound (POCUS) teaching sessions over a year, each session focusing on several distinct concepts. The sessions included lectures and hands-on teaching with both healthy volunteers and with patients in the various communities. Over the 12 months, the POCUS were logged and the majority of images saved. The logs were analyzed to determine if POCUS affected the medical management of the patients. The primary investigator reviewed 35.2% of the total ultrasounds completed, which was 52.2% of the save images, for quality assurance and feedback.

Results

Over the 12 months, there were 584 ultrasound studies documented. The most common study was a transabdominal obstetric examination (45.5%) followed by abdomen/pelvis (26.6%) and musculoskeletal (5.7%) and skin and soft tissue (5.7%). The use of POCUS changed the patient diagnosis after 194 scans (34%) and changed the clinical management for the patient encounter in 171 (30%) scans. In the 194 scans in which POCUS changed the diagnosis, the clinical management was changed, as a direct result of the scan results, in 152 (78.4%) of those patient encounters.

Conclusion

A longitudinal POCUS educational curriculum is an effective way to equip local physicians in resource limited countries with a tool to improve their clinical management of patients.

Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis

OBJECTIVE

Although a clinical diagnosis, the standard initial imaging modality for patients with concern for pediatric community acquired pneumonia (pCAP) is a chest x-ray (CXR), which has a relatively high false negative rate, exposes patients to ionizing radiation, and may not be available in resource limited settings. The primary objective of this meta-analysis is to evaluate the accuracy of lung ultrasound (LUS) compared to CXR for the diagnosis of pCAP.

METHODS

Data were collected via a systematic review of PubMed, EMBASE, and Web of Science with dates up to August 2017. Keywords and search terms were generated for pneumonia, lung ultrasound, and pediatric population. Two independent investigators screened abstracts for inclusion. PRISMA was used for selecting appropriate studies. QUADAS was applied to these studies to assess quality for inclusion into the meta-analysis. We collected data from included studies and calculated sensitivity, specificity, positive predictive value, and negative predictive values of CXR and LUS for the diagnosis of pCAP.

RESULTS

Twelve studies including 1510 patients were selected for data extraction. LUS had a sensitivity of 95.5% (93.6-97.1) and specificity of 95.3% (91.1-98.3). CXR had a sensitivity of 86.8% (83.3-90.0) and specificity of 98.2% (95.7-99.6). Variations between the studies included ultrasound findings diagnostic of pneumonia, study setting (inpatient vs emergency department) and inclusion of CXR in the reference standard for pneumonia.

CONCLUSIONS

In our meta-analysis, lung ultrasound had significantly better sensitivity with similar specificity when compared to chest x-ray for the diagnosis of pediatric community acquired pneumonia.

Obstetric ultrasound use in low and middle income countries: a narrative review

INTRODUCTION

Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited. Hence, questions around the purpose and the intended benefit as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric ultrasound technology in low-and middle-income countries (LMICs).

MAIN BODY

This narrative review discusses these issues for those trying to implement or scale-up ultrasound technology in LMICs. Issues addressed in this review include health personnel capacity, maintenance, cost, overuse and misuse of ultrasound, miscommunication between the providers and patients, patient diagnosis and care management, health outcomes, patient perceptions and concerns about fetal sex determination.

CONCLUSION

As cost of obstetric ultrasound becomes more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation. Additionally, there is a need to more clearly identify the capabilities and the limitations of ultrasound, particularly within the context of limited training of providers, to ensure that the purpose for which an ultrasound is intended is actually feasible. We found evidence of obstetric uses of ultrasound improving patient management. However, there was evidence that ultrasound use is not associated with reducing maternal, perinatal or neonatal mortality. Patients in various studies reported to have both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex was raised as a concern.

Measurement error of mean sac diameter and crown-rump length among pregnant women at Mulago hospital, Uganda

Background

Ultrasonography is essential in the prenatal diagnosis and care for the pregnant mothers. However, the measurements obtained often contain a small percentage of unavoidable error that may have serious clinical implications if substantial. We therefore evaluated the level of intra and inter-observer error in measuring mean sac diameter (MSD) and crown-rump length (CRL) in women between 6 and 10 weeks’ gestation at Mulago hospital.

Methods

This was a cross-sectional study conducted from January to March 2016. We enrolled 56 women with an intrauterine single viable embryo. The women were scanned using a transvaginal (TVS) technique by two observers who were blinded of each other’s measurements. Each observer measured the CRL twice and the MSD once for each woman. Intra-class correlation coefficients (ICCs), 95% limits of agreement (LOA) and technical error of measurement (TEM) were used for analysis.

Results

Intra-observer ICCs for CRL measurements were 0.995 and 0.993 while inter-observer ICCs were 0.988 for CRL and 0.955 for MSD measurements. Intra-observer 95% LOA for CRL were ± 2.04 mm and ± 1.66 mm. Inter-observer LOA were ± 2.35 mm for CRL and ± 4.87 mm for MSD. The intra-observer relative TEM for CRL were 4.62% and 3.70% whereas inter-observer relative TEM were 5.88% and 5.93% for CRL and MSD respectively.

Conclusions

Intra- and inter-observer error of CRL and MSD measurements among pregnant women at Mulago hospital were acceptable. This implies that at Mulago hospital, the error in pregnancy dating is within acceptable margins of ±3 days in first trimester, and the CRL and MSD cut offs of ≥7 mm and ≥ 25 mm respectively are fit for diagnosis of miscarriage on TVS. These findings should be extrapolated to the whole country with caution. Sonographers can achieve acceptable and comparable diagnostic accuracy levels of MSD and CLR measurements with proper training and adherence to practice guidelines.