Tele-reading & Training: WFPI projects

© Philippe Devred

For worldwide education initiatives, see here 




Which tele-platforms support WFPI's work? Click here 



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, with Dr. Kay North and the Children's Mercy Hospital, Kansas, USA, leading the support. WFPI delivered a new portable ultrasound machine, donated to Pothawira by Dr. Kristen DeStiger of Imaging the World, in view of a future ITW/Kansas 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



ITW

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.

Progress report, 1st December 2014

  • 36 referrals to date: mostly chest CTs, a few abdominal CTs , a few head CTs
  • Time range from request to report: 0 to 4d, mean 2d, median 2d excluding w/ends - i.e requested Saturday, reported Monday: = 2 days
  • Most patients: findings suspicious for tuberculosis or fungal disease Referring radiologist, IGICH: Dr. Ramesh Nayak Active WFPI volunteer readers: Drs. Aadil Ahmed (South Africa),   Jon Brandon (USA), Preeyacha Pacharn (Thailand), Cicero Silva (USA)
  • Recently joined the WFPI volunteer team: Dr. Goran Djuricic
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; 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.

 

 

PROJECTS IN THE PIPELINE OR JUST STARTED

Angkor Hospital for Children, Siem Reap, Cambodia

Angkor Hospital for Children (AHC) is a 103 bed charity pediatric hospital serving children affected by poverty and disease. Founded in 1999, the hospital has grown to include a 12 bed intensive care unit, a surgery program including open heart surgery cases assisted by visiting teams, the beginnings of a cancer care program, a neonatal ward and a newly renovated and expanded outpatient department. More information can be found at www.angkorhospital.org.

AHC’s two radiology modalities are X-ray and ultrasound (no CT scanner or MRI Machine. CT scans are occasionally obtained at other facilities in Siem Reap on an as needed basis.) The good quality images are done with a very simple mobile machine. A phosphor plate system is in place, thus X-Rays and descriptions can be reached from the ward. ACH uses SONIX SP (ultrasonix) ultrasound machine with three probes:  C7-3/50 , L14-5/38 and PA4-2/20. Since its repair in early March 2014, the machine has ceased to function with Pulsed and Power Doppler. There are 15-20 ultrasound examinations/day, mainly severe  soft tissue masses and eye injuries. There is no small convex probe. Generally speaking there are no normal finding, just severe pathologies. AGH has one radiologist and plans to add an additional physician to train as a pediatric radiologist. To date, AGH refers I case per week to WFPI. 

Site coordinator: Dr. Seng Hap. WFPI coordinators: Drs. Veronica Donoghue and Eva Kis. Project identified by Dr. Catherine Owens/Royal College of Radiologists, UK 

© Cambodia images: George Taylor 



Central and Eastern Europe

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 other and partner facilities in Western Europe. Map left: the CEEPUS network. Click here for more project information (slow file to open)

Tele-reading sites in the pipeline:
The department of Pediatrics, University Hospital Saint George, Plovdiv, Bulgaria. 86 pediatric beds,16 General Radiologists, 1 Pediatric Radiologist, 2 MRI specialists (not pediatric MRI). Major constraint: little experience with pediatric MRI. More news soon as this project develops.  

 University Hospital Saint George, Plovdiv, Bulgaria
 

 

Bustamante Children's Hospital, Kingston, Jamaica

Bustamante Children's Hospital offers 283 beds, including 5 in the ICU. The hospital is usually overcrowded and has long waiting times for diagnostic and medical interventions as well as outpatient consultations. The Accident and Emergency department operates on a 24/7 basis and sees approximately 77,000 patients per year.

The imaging department serves an overwhelming number of about 4000 patients for examinations per month from all over the Island (the vast majority is outpatient). CT scans and MRIs are done on about 80 and 20 pediatric patients respectively per month. 

Site coordinator: Dr. Marcia Lawrence. WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez and PAHO/WHO.

Click here for more information

 

Wendy Fitzgerald Paediatric Hospital, Trinidad 

This pediatric hospital, managed by a regional health authority, is part of the national health system. It is the only pediatric facility for 2 regions (out of 5) and offers 275 beds. There are 7 general radiologists on its staff. A new national children's hospital is under construction and will eventually offer all pediatric imaging services. The 9 year old 16 slice CT is in working order. Pediatric CTs and sonography are performed in a separate building in the nearby campus of the Eric Williams Medical Sciences Complex. There is a plain radiology unit in the emergency department of the Wendy Fitzwilliam Paediatric Hospital. 

Site coordinator: Dr. Paramanand Maharaj, WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez and PAHO/WHO.

Click here for more details

 

  

Hospital Regional de Iquitos, Peru

Iquitos is encircled by rivers and rainforest and is the world’s largest city with no roads connecting it to the outside world. The Regional Hospital is a public facility serving over 1 million
people. It offers 93 pediatric beds including PICU-NICU. Patients transferred from here to Lima if required. There are 2 general radiologists. Equipment (non-digital) includes 2 X-ray machines, 2 U/S machines and 1 CT.

Site coordinator: Dr. Raul Seminario, WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez.

See here for more striking images of Iquitos Regional Hospital


 

 

Centro de Salud Santa Clotilde(CSSC), Napo River, Peru.


This 30-bed hospital includes a general medical area, a labour and delivery room, an operating room, a clinic and a laboratory. The CSSC is the head of a network of 12 health facilities along 400km of the Napo River and serves 100+ villages and a population of over 20,000. In 2010 there were 15,000 outpatient visits and 903 admissions to the hospital with 62 deliveries and 71 surgeries. Patients unable to be treated at the CSSC are stabilized and transferred to Iquitos via a one day boat trip and if needed flown to Lima. The Centre offers 1 U/S machine and no X-ray machine (work in progress).
 
Site coordinator: Dr. Brian Medernach, WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez 


   More images here

    

  



Hospital de Cobán, Alta Varapaz, Guatemala

This hospital is the only third level hospital in the region. It offers 180 beds, 1 general radiologist, 1 U/S, an X-ray room, 1 portable X-ray. The site is non-digital. CT belongs to a large private group and cases are sent and read outside (external PACS).

Site coordinator: Dr. José Pineda, WFPI coordinator: Ramon Sanchez. Project identified by Dr. Ramon Sanchez.

More details available here


 

Palestine

Following Dr. Aadil Ahmed's visit to Gaza in June 2013 (see here), WFPI is now providing tele-opinion support to Nasser Children's Hospital with extension to Rantissi Hospital planned. The team from SIDRA Medical and Research Centre, Doha Qatar, plan to join this tele-reading team; there are hopes for later onsite training. 

 

CT, Rantissi Hospital, Gaza


Site coordinator: Dr. Hossam Ahmed ELNajili, WFPI coordinator: Dr. Aadil Ahmed. Project identified by Dr. Aadil Ahmed.