Tele-reading & Training: WFPI projects

Malawi

Project identified by Drs. Savvas Andronikou, Arthur Daire (Blantyre), Peter Maseko (Salima) and Kristen DeStigter (Imaging the World)

In July 2014 WFPI undertook an exploratory outreach mission to teach and determine pediatric radiology needs in different environments in Malawi. The visit aimed to provide tele-reading support for pediatric imaging and pave the way for future teaching and training visits.

Dr. Tracy Kilborn (Head of Pediatric Imaging, Red Cross War Memorial Children’s Hospital, Cape Town) volunteered for the trip. A member of the South African Pediatric Imaging Society and a WFPI tele-reading volunteer, Dr. Kilborn's geographical proximity and experience with endemic diseases, equipment constraints and environmental limitations leave her well equipped for regional outreach.

The trip covered 4 different health facilities in Malawi

  • Queen Elizabeth Hospital, Blantyre
  • Chiradzulu District Hospital - MSF AIDS-HIV project
  • Kamuzu Central Hospital, Lilongwe
  • Pothawira Haven, Salima

Dr. Tracy Kilborn with Dr. Peter Maseko, Pothawaria Haven Salima, Malawi

Queen Elizabeth Hospital Blantrye offers 300 Pediatric beds and conducts 100,000 Pediatric reviews per year in A/E with 20,000 Pediatric admissions per year. A 0.75T open magnet, installed by Johns Hopkins as a research magnet, is used by the hospital. A CT machine purchased 4 years ago is in storage while waiting for a room to be built. The sole MoH radiologist is stretched to support radiography and ultrasound as well as MRI.  

Right: Dr Arthur Dale, MoH radiologist, Queen Elizabth Hospital Blantyre

Below: Paediatric Ward, Queen Elisabeth Hospital, Blantyre


Teaching activities in Blantyre and at Kamauzu Central Hospital in Lilongwe included lectures to the paediatric and paediatric surgical staff on:

  • Approach to a paediatric CXR,
  • Approach to a paediatric AXR, 
  • Imaging of neonatal GI emergencies, 
  • Imaging of non-accidental injuries, 
  • Basic approach to nuclear medicine in renal disorders

along with teaching paediatric ultrasound techniques to sonographers, consultations on complex medical and surgical cases and engaging in discussions on CXR technique with radiographers.

Among the conclusions of the trip: Point of Care (PoC) ultrasound in all the facilities visited would be of immense relevance and value.

At Pothawira Haven, Salima, Dr. Peter Maseko (image left), 4 nurses and an occasional volunteering medical student run a clinic that sees 200-300 patients a day. Pothawira also supports 110 orphans, all of whom live and are schooled at the Haven. The entire project is funded through donations. WFPI delivered a new portable ultrasound machine, donated to Pothawira by Dr. Kristen DeStiger of Imaging the World in view of a future ITW project in Malawi that WFPI hopes to partner with. Accompanied by a radiologist resident from Lilongwe, Dr. Pamela Gunde (image below) and with excited orphans queueing up as teaching material, the ultrasound training at the clinic began. After 2 days, the two physicians could competently scan pediatric heads, chests, abdomens and look for pericardial effusions. 

 

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WFPI is conducting research on volume sweep ultrasound for use in precisely this type of setting: see here

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 Chiradzulu District Hospital, where suspicions run deep that Childhood TB is severely underdiagnosed
 Happy volunteers for the ultrasound training...! 
 Kamuzu Central Hospital, Lilongwe



 

.... in Uganda, plans for Malawi


WFPI hopes to partner with Imaging the World (ITW, www.imagingtheworld.org) in its future Malawi work so as to move PoC ultrasound forward in Pothawira Haven and elsewhere. 

ITW's work, based in Uganda to date, involves non-radiologists acquiring ultrasound images using anatomical landmarks on the skin and storing US sweeps as cine-loops in a standard format, to be read by radiologists at a distance (tele-reading). 

ITW has no pediatric protocols, so pediatric radiologist Dr. Julie Hurteau (Children's Hospital of Eastern Ontario, University of Ottawa, Canada) and Dr. Sabine Bélard (Charité University Hospital, Berlin, Germany) joined Dr. Kristen DeStigter (Fletcher Allen Health care, University of Vermont, Canada, and founder of Imaging the World) on Dr. DeStigter's latest trip to Uganda in August 2014. Dr. Bélard has been involved in WFPI's research on pediatric protocols for volume sweep ultrasound in Cape Town since 2013.

The aim: explore perspectives for establishing ultrasound as a diagnostic modality for pediatric pneumonia and tuberculosis in rural Uganda and set up some foundations for future ITW-WFPI collaboration in Malawi. 


Dr. Julie Hurteau with Sister Angela, the heart and soul of the rural health clinic of Nawanyago in Kamuli, and Dr. Kristen DeStigter.

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A few figures for Uganda 

Uganda Population 2012 – 32.2 M
Expected population in 2020 – 44M
Ugandan population living in rural areas -84%
Total number of doctors in Uganda – 644
% of doctors in urban areas – 70%
Number of radiologists in Uganda – 34. This means that more than 80% of Ugandans (rural) have access to only 30% of the medically trained health care providers. Also they are seen at primary health care facilities which mostly lack any imaging facilities. 

How about diseases in Uganda?                                                                                                                           
Acute respiratory infections - cause 15% of all deaths in children under five years of age                          
HIV prevalence - around 7%                                                                                                                              
Tuberculosis incidence - 175/100000 annually                                                                                                       
Pediatric tuberculosis - up to 20% of the tuberculosis case load

 

Dr Bélard conducting a hands-on scanning session at the Mubende Regional Referral Hospital

Click here for more on Imaging the World


MSF

Médecins Sans Frontières/Doctors without Borders

Project identified by Dr. Savvas Andronikou

Tele-reading

 The WFPI is collaborating with MSF to provide pediatric imaging telereporters to support MSF’s global telemedicine network, using platforms and technology already set up in project sites.

Four WFPI volunteers are enlisted on the Collegium Telemedicus platform. Well over 100 radiographs have been read to date, with subsequent exchange occurring on some cases. Projects covered are in the CAR, Tajikistan, Malawi and Cambodia. The platform is rudimentary, but works. Quality is highly variable.

See WFPI's mini-symposium, "Outreach in the Developing World" for articles on MSF's tele-radiological history and quality assurance/lessons learnt. 

Discussions are underway with MSF's diagnostic imaging network for expanding WFPI's support. Our strong tuberculosis focus dovetails with MSF's massive TB drive: see here for MSF's TB overview, associated literature and films 

  

Click on the image to find out more about MSF's drug-resistant TB manifesto, signed by WFPI 


Other MSF work

MSF sends doctors to South Africa for HIV training where pediatric imaging sessions are delivered by the WFPI.

The WFPI's Outreach Leader, Savvas Andronikou, assists in the production of MSF diagnostic guidelines and recently co-authored an article on a quality assessment of X-rays interpreted via tele-radiology for MSF, accepted for publication in the Journal of Telemedicine and Telecare. Two "Seven Minute Snippets" (short videos) on the interpretation of pediatric tuberculosis CXR films were co-produced with MSF in South Africa: see here

IGICH

Indira Ghandi Institute of Child Health, Bangalore, India

Project identified by Drs. Catherine Owens & Samantha Sonnappa, GOSH, UK. IGICH lead: Dr. Ramagatta. L. Ramesh. WFPI project lead: Dr. Cicero Silva

A WFPI tele-reading project is underway at the Indira Ghandi Institute of Child Health (IGICH), Bangalore, a 250 bed children hospital supported by UNICEF and WHO. The hospital's radiology department performs an average of 1000 X-rays, 500 US and 150 CT scans per month with only one radiologist onsite.

WFPI's Telecommunications Committee developed a tele-platform for this project's use.  


Progress report, 4th August 2014

Total of 31 cases, most chest CTs, a few abdominal CTs and a few head CTs.
Time range study reaches WFPI coordinator -> report is fed into software: 0 to 4 days, mean 1.8 day, median 2 days (that does not exclude weekends - i.e. if a study is received on a Saturday and reported on a Monday we consider 2 days time range).
Findings in most patients: suspicious for tuberculosis or fungal disease.
Referral radiologist, IGICH: Dr. Ramesh Ramagatta Lakshamana Nayak. 
WFPI volunteers reporting: Drs. Aadil Ahmed, Jon Brandon, Sarah Desoky, Preeyacha Pacharn, Cicero Silva. 
Thanks to Drs. Ramesh and Cicero Silva, Michael Engelhardt of SUSTSOL, Prof. Erich Sorantin and the WFPI team for the patience and tenacity displayed in getting this project off the ground.

Click here

for more information on the IGICH

     
Dr. Ramesh R.L., radiologist, IGICH 
              
 
Dr. Cicero Silva, WFPI coordinator (Yale, USA)

Drs. Ramesh and Silva meet up at last! ISPR Annual Conference, Vellore, India, September 2014


Khayelitsha

Khayelitsha, Western Cape, South Africa


Project identified by Dr. Savvas Andronikou MD and the South African Society of Pediatric Imaging (SASPI)

Project start-up

WFPI began tele-reading chest and other plain X-rays  for Khayeltisha Hospital, Western Cape, South Africa, in July 2012. Starting with 5 South African readers, the team reached  50 volunteer tele-readers worldwide and has read over 500 X-rays to date. Radiographs are digital, converted to JPEG. Their quality is adequat for interpretation.

Image left: Dr Harlem Gongxeca, a SASPI member and practicing pediatric radiologist in South Africa who voluntarily tele-reads for Khayelitsha and the WFPI 

Project roll-out: ups & downs!

The project wound down in early 2013 following the departure of the onsite technician (responsible for referring films to WFPI). It re-started in September 2013, with a transfer of tele-reading from WFPI to Stanford University Hospital, USA, as part of WFPI's drive to set up partnerships between facilities in lower resource and modern medical settings. Referrals come from the facility's clinicians as opposed to the technician team, resulting in a reduced flow of problem cases only: an excellent development which avoids WFPI substitution of basic imaging services and places us in a role of "provider of expert second opinions".

The activity flow has been through further stops and starts since. Each clinician needs internet access for tele-platform use, which has proven problematic.

The WFPI-Stanford tele-support role has been confirmed for the time being; the Red Cross Memorial Children's Hospital and WFPI will provide onsite lectures and training to strengthen pediatric imaging knowledge.

 Project backround: click here

ONSITE TRAINING

Savvas Andronikou delivered an on-site training session for non-radiologists in October 2012 and January 2013. The visits proved useful for exposing problems and re-orientating the WFPI’s work accordingly  and reinforced the necessity to back up WFPI tele-reading with training and education. Some can be delivered online, but onsite visits are key to success.

Project reports: click here


AUDIT & EVALUATION

WFPI has published an audit and sustainability evaluation of its tele-reading for Khayelitsha in WFPI's mini-symposium, "Outreach in Developing Countries": click here.

 

 

Central Europe

WFPI in Central and Eastern Europe

 

 

The WFPI is looking to expand its pediatric imaging support to Central and Eastern Europe. Future projects are likely to draw on health facilities forming part of the CEEPUS network (Central Europe Exchange Programme for University Studies) which links up facilities with each othere and partner facilities in Western Europe.

The WFPI would offer tele-reading support for facilities lacking pediatric imaging expertise, tied into existing educational and training programs run by CEEPUS.

This project is under development - we will post more details as our plans take shape

MAP: the CEEPUS network. Click here for more project information (slow file to open)

 

WATCH THIS SPACE!!

Click here
for a project start-up form submitted by
Clinical Hospital of Tetovo, Macedonia 

Zdravstveni Centar Studenica, Serbia
A CEEPUS member and possible WFPI project site

 ITW