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.

Skin Nodules as a First Presentation of Synchronous Bilateral Invasive Lobular Breast Carcinoma: A Case Report

The most common cause of skin metastases in adult women is primary breast carcinoma, which comprises about 70% of cases [1]. Skin metastases have non-specific clinical appearances, making it challenging to differentiate them from other benign conditions [1]. We present a case of a 52-year-old female with type II diabetes and a three-month history of refractory skin lesions who did not respond to anti-inflammatory treatment. The patient subsequently complained of a right breast lump, evaluation of which led to the diagnosis of bilateral synchronous invasive lobular carcinoma.

Renal Artery Pseudo-aneurysms: Do All of Them Require Endovascular Management?

Purpose: Our study examines the etiological profile, clinical and imaging features of renal artery pseudo aneurysms (RAPs), as well as the efficacy and need for the angioembolization of RAPs in a resource-constrained setting. Materials and Methods: A total of 36 patients with RAPs were included in our study. Initial diagnosis was made by Doppler Ultrasonography (USG) followed by CT renal angiography in all cases. DSA was performed in 28 patients, as eight patients showed spontaneous resolution by thrombosis on immediate pre-procedure Doppler study. Angioembolization with a microcoil was performed for 30 aneurysms in 28 patients. Technical success was confirmed at the end of the procedure by a renal angiogram. To assess clinical success, we followed up with patients (with clinical and Doppler USG) for a period of six months. Results: The most common cause of RAPs in our study was percutaneous nephrolithotomy (PCNL), seen in 21 patients (58.3%), followed by trauma (25%), and partial nephrectomy (11%). All patients presented to us were within 21 days of the etiological event of hematuria or flank pain. USG was able to detect the RAP in 22 cases (61%). CT renal angiography was diagnostic in all patients but failed to demonstrate two additional aneurysms in one patient. RAP size ≤ 4 mm and absence of brisk filling on CT renal angiography was associated with spontaneous resolution in eight patients, probably an indication of the beginning of spontaneous thrombosis. Angioembolization was done using microcoils and showed 100% technical and clinical success. Conclusion: PCNL is the most common etiological factor for RAPs in our setting. Such patients should have a Doppler USG done prior to discharge from the hospital. CT angiographic flow dynamics (delayed peak enhancement) may be helpful in the identification of RAPs with a high probability of subsequent spontaneous resolution. Angiography followed by embolization using microcoils is the most effective and safe treatment for RAPs with no significant loss of renal parenchyma, although cost remains a limiting factor in our setting.

Global Health Leadership Pathway: A Novel Approach to Global Radiology Curriculum Integration for Residents

Purpose: Our radiology residency programs are at an academic medical center in the southeastern United States and are accredited by the Accreditation Council for Graduate Medical Education (ACGME). During the initial eight years of our department’s global health program, 22 residents participated in our global health collaborations with a related $31,000 in extradepartmental travel awards. Increasingly, residents applying to our program convey interest in the integration of global health into their careers as radiologists. To that end, our administration, global health faculty, and residency program directors created and approved a Global Health Leadership Pathway (GHLP). The Pathway spans all years of radiology training to provide curriculum support with the aim of ensuring that our residents have the knowledge and skills necessary to become future leaders in global health. Description: The GHLP is a residency track that residents apply to join with a related radiology clinical education, global health specific curriculum throughout all training years, integration of the RAD-AID Certificate of Proficiency in Global Health Radiology, individual mentorship, and participation with an international elective. Structured education on global radiology, epidemiology, access implications, and related methodologies give our residents the opportunity to learn best practices for sustainability in global health. Conclusion: Because of increasing interest and due to the past successful involvement of our radiology residents in global health, our department created this Global Health Leadership Pathway to give our trainees the educational resources to support their future leadership and involvement in the academic field of global health.

Validation of a Locally Designed Computed Tomography Dose Phantom: A Comparison Study with a Standard Acrylic Phantom in South-South, Nigeria

Purpose: The aim of this study was to determine the mean volume computed tomography dose index (CTDIvol) for the standard head and body phantoms and locally designed head and body phantoms respectively. Similarly, this study determined and compared the displayed mean CTDIvol and Dose Length Product (DLP) for the above phantoms from the CT monitor. In addition, the percentage deviations of both phantoms were compared with the recommended limits from the International Atomic Energy Agency (IAEA) and the American College of Radiologists (ACR). Materials and Methods: Dose measurements were made using a standard polymethymethacrylate (PMMA) phantom for head and body as well as a locally designed phantom with four CT scanners using thermoluminescence dosimeters (TLDs). The locally designed phantoms were made using a PMMA sheet, which was bent to give the desired cylindrical shape and was made like the standard phantoms. The constructed phantom was filled with water and the TLD chips were inserted into the center and peripheries of the phantoms to obtain the absorbed doses. Results: The CTDIvol for the standard head and body phantom for center A was 66.97 and 21.85mGy and for B was 23.39 and 6.29mGy respectively. Similarly, the CTDIvol for the constructed head and body phantom for center A was 63.91 and 19.84mGy and for B was 24.67 and 6.30mGy respectively. The uncertainty between the standard and constructed head phantoms for centers A and B was 4.6 and 5.5% respectively, while that of the standard and constructed body phantoms for centers A and B was 9.2 and 0.0% respectively. The maximum percent deviation from the console CTDIvol and DLP values with the four phantoms for centers A and B was within ±20%. The mean correction factors for the head and body were 0.998 and 1.05 respectively. Conclusion: The uncertainties obtained in this study were within the IAEA and ACR recommended value of ±20%. The constructed phantom proved useful for CT dose measurements.

Determination of Calibration Factors and Uncertainties Associated with the Irradiation of MTS-N (LiF: Mg, Ti) Chips with Cesium-137 and X-ray Sources Under Low Doses for Personal Dosimetry in Diagnostic Radiology

Purpose: The purpose of this study was to compare calibration factors for deep dose equivalent Hp (10) and shallow dose equivalent Hp (0.07) between Cesium (Cs)-137 and X-ray sources when they are exposed to same dose and to determine uncertainties with MTS-N (LiF: Mg, Ti) chips when they are exposed to low dose ≤ 2mGy. Material and Methods: Thermoluminescent (TL) chips were annealed at 400oC for one hour and allowed to cool and were subjected to a temperature of 100oC for another two hours using a TLD Furnace Type LAB-01/400. They were then taken to a Secondary Standard Dosimetry Laboratory (SSDL) for irradiation using a Cs-137 source at known doses (0.2-2mGy). A RadPro Cube 400 manual TLD Reader was used to determine corresponding TL signal. The above process was replicated but with a calibrated X-ray unit as the source for calibration. Results: The calibration factors (CF) from the line graph of dose (mGy) against TL signal (count) for Cs-137 source with Hp (10) and Hp (0.07) were 3.72 x 10-6 and 5.97x10-6 mGy/count respectively. Those with X-ray source for Hp (10) and Hp (0.07) were 3.44x10-6 and 4.05x10-6 mGy/count respectively with an overall coefficient of determination (R2) = 0.99. The adjusted maximum percentage deviation between the actual and calculated dose for both sources was -2.74%. The percent (%) deviation of the mean with both sources for Hp (10) and Hp (0.07) was 3.9% and 19% respectively. Conclusion: Adjusted percent deviation from both sources were within the recommended dose limit of ±30% by the Radiological Protection Institute of Ireland (RPII) and within the International Commission on Radiological Protection (ICRP) limit respectively. Better accuracy was seen for Hp (10) with both sources compared to Hp (0.07). Calibration of the MTS-N chips using both sources was successful and can be used for personal dosimetry.

Finding Meaningful Opportunities During the COVID-19 Crisis: Developing an International Radiology Elective in Cameroon

Teleradiology and remote video conferences can provide radiology residents the opportunity to participate in global radiology outreach. We reflect on how social distancing measures and remote education resources developed to address COVID-19 were applied to developing an international radiology elective.

Experience with an ultrasound donation program in a low-income country

Increasing radiology capacity in low-income countries (LIC) can improve clinicians’ access to diagnostic imaging tools and improve patient care. Ultrasound (US) is important in LIC due to its lower cost compared to that of CT or MRI scans and its excellent diagnostic ability. The relative portability of the equipment makes it ideal for donation by charitable organizations. We describe our experience as a radiology-capacity-focused charity working with the Haitian healthcare system and propose strategies to increase ultrasound capacity in other poor countries.

The State of Interventional Radiology in Myanmar: A National Report

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.

Radiology Education and the Quality of Care: Radiation Dose

The purpose of this quantitative, quasi-experimental study was to analyze whether the education of radiology personnel mandated by the American Registry of Radiologic Technologists (ARRT) affects the quality of care delivered to radiology patients. One area of radiology quality of care was focused on the findings presented in this study: radiation dosage. Three groups of study participants were used. The participants were chosen and divided into groups based on their radiology background, non-radiology medical background, or lack of medical background. All study participants were required to complete an assessment asking participants what radiation dosage and shields they would use for a standard set of radiographic examinations. A training video was shown to those participants with no radiology background prior to the assessment. The data provided by each group was compared to determine similarities and variances between the groups and ANOVA calculations were completed. Differences were found between the assessments completed by members of all three groups. The results support the perception that ARRT-mandated education does affect radiation dosage chosen in the care of radiology patients.