Standardization and quality control of Doppler and fetal biometric ultrasound measurements in low-income setting.

OBJECTIVE: The aim of this study was to determine the quality of fetal biometry and pulsed-wave Doppler ultrasound measurements in a prospective cohort study in Uganda. METHODS: This was an ancillary study of the Ending Preventable Stillbirths by Improving Diagnosis of Babies at Risk (EPID) project, in which women enroled in early pregnancy underwent Doppler and fetal biometric assessment at 32-40 weeks of gestation. Sonographers undertook 6 weeks of training followed by onsite refresher training and audit exercises. A total of 125 images for each of the umbilical artery (UA), fetal middle cerebral artery (MCA), left and right uterine arteries (UtA), head circumference (HC), abdominal circumference (AC) and femur length (FL) were selected randomly from the EPID study database and evaluated independently by two experts in a blinded fashion using objective scoring criteria. Inter-rater agreement was assessed using modified Fleiss' kappa for nominal variables and systematic errors were explored using quantile-quantile (Q-Q) plots. RESULTS: For Doppler measurements, 96.8% of the UA images, 84.8% of the MCA images and 93.6% of the right UtA images were classified as of acceptable quality by both reviewers. For fetal biometry, 96.0% of the HC images, 96.0% of the AC images and 88.0% of the FL images were considered acceptable by both reviewers. The kappa values for inter-rater reliability of quality assessment were 0.94 (95% CI, 0.87-0.99) for the UA, 0.71 (95% CI, 0.58-0.82) for the MCA, 0.87 (95% CI, 0.78-0.95) for the right UtA, 0.94 (95% CI, 0.87-0.98) for the HC, 0.93 (95% CI, 0.87-0.98) for the AC and 0.78 (95% CI, 0.66-0.88) for the FL measurements. The Q-Q plots indicated no influence of systematic bias in the measurements. CONCLUSIONS: Training local healthcare providers to perform Doppler ultrasound, and implementing quality control systems and audits using objective scoring tools in clinical and research settings, is feasible in low- and middle-income countries. Although we did not assess the impact of in-service retraining offered to practitioners deviating from prescribed standards, such interventions should enhance the quality of ultrasound measurements and should be investigated in future studies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

OCCUPATIONAL DOSE AND RADIATION PROTECTION PRACTICE IN UAE: A RETROSPECTIVE CROSS-SECTIONAL COHORT STUDY (2002-2016).

A two-phased retrospective cross-sectional study analysed the occupational dose and radiation protection practice among medical workers in two hospitals in the UAE. Phase 1 evaluated radiation protection practice using a questionnaire, whereas phase 2 assessed the occupational dose. Readings of 952 thermoluminescence dosimeters were analyzed. The result showed 52% of medical workers have a good level of radiation protection practice. Readings of 952 thermoluminescence dosimeters were analyzedAverage annual effective dose per worker ranged from 0.39 to 0.83 mSv. Cardiologists and nurses displayed a higher average of occupational radiation dose compared to other workers. There were no significant correlations between radiation protection practice and hospital, occupation or department. Finally, the occupational dose was within the international and national limits, but the reduction of radiation dose to cardiologist and nurses is essential. Moreover, training is essential to promote radiation safe practice among medical workers.

The diagnostic impact of limited, screening obstetric ultrasound when performed by midwives in rural Uganda.

OBJECTIVE: To evaluate the diagnostic impact of limited obstetric ultrasound (US) in identifying high-risk pregnancies when used as a screening tool by midwives in rural Uganda. STUDY DESIGN: This was an institutional review board-approved prospective study of expecting mothers in rural Uganda who underwent clinical and US exams as part of their standard antenatal care visit in a local health center in the Isingiro district of Uganda. The midwives documented clinical impressions before performing a limited obstetric US on the same patient. The clinical findings were then compared with the subsequent US findings to determine the diagnostic impact. The midwives were US-naive before participating in the 6-week training course for limited obstetric US. RESULT: Midwife-performed screening obstetric US altered the clinical diagnosis in up to 12% clinical encounters. This diagnostic impact is less (6.7 to 7.4%) if the early third trimester diagnosis of malpresentation is excluded. The quality assurance review of midwives' imaging demonstrated 100% sensitivity and specificity in the diagnosing gestational number, and 90% sensitivity and 96% specificity in the diagnosis of fetal presentation. CONCLUSION: Limited, screening obstetric US performed by midwives with focused, obstetric US training demonstrates the diagnostic impact for identifying conditions associated with high-risk pregnancies in 6.7 to 12% of patients screened. The limited obstetric US improved diagnosis of early pregnancy complication as well as later gestation twins and malpresentation. Midwives who have undergone focused 6-week limited obstetric US training proved capable of diagnosing twins and fetal presentation with high sensitivity and specificity.

Chest radiographic findings of pulmonary tuberculosis in severely immunocompromised patients with the human immunodeficiency virus.

OBJECTIVE: We describe chest radiograph (CXR) findings in a population with a high prevalence of human immunodeficiency virus (HIV) and tuberculosis (TB) in order to identify radiological features associated with TB; to compare CXR features between HIV-seronegative and HIV-seropositive patients with TB; and to correlate CXR findings with CD4 T-cell count. METHODS: Consecutive adult patients admitted to a national referral hospital with a cough of duration of 2 weeks or longer underwent diagnostic evaluation for TB and other pneumonias, including sputum examination and mycobacterial culture, bronchoscopy and CXR. Two radiologists blindly reviewed CXRs using a standardised interpretation form. RESULTS: Smear or culture-positive TB was diagnosed in 214 of 403 (53%) patients. Median CD4+ T-cell count was 50 cells mm(-3) [interquartile range (IQR) 14-150]. TB patients were less likely than non-TB patients to have a normal CXR (12% vs 20%, p = 0.04), and more likely than non-TB patients to have a diffuse pattern of opacities (75% vs 60%, p = 0.003), reticulonodular opacities (45% vs 12%, p < 0.001), nodules (14% vs 6%, p = 0.008) or cavities (18% vs 7%, p = 0.001). HIV-seronegative TB patients more often had consolidation (70% vs 42%, p = 0.007) and cavities (48% vs 13%, p < 0.001) than HIV-seropositive TB patients. TB patients with a CD4+ T-cell count of ≤ 50 cells mm(-3) less often had consolidation (33% vs 54%, p = 0.006) and more often had hilar lymphadenopathy (30% vs 16%, p = 0.03) compared with patients with CD4 51-200 cells mm(-3). CONCLUSION: Although different CXR patterns can be seen in TB and non-TB pneumonias there is considerable overlap in features, especially among HIV-seropositive and severely immunosuppressed patients. Providing clinical and immunological information to the radiologist might improve the accuracy of radiographic diagnosis of TB.

Learning Radiology in an Integrated Problem-Based Learning (PBL) Curriculum

Background: The Faculty of Medicine (FoM) has been training health professions in Uganda since 1924. Five years ago; it decided to change the undergraduate curriculum from traditional to Problem Based Learning (PBL) and adopted the SPICES model. Radiology was integrated into the different courses throughout the 5 year program. The objective was to improve the implementation of the integration of Radiology in the integrated PBL curriculum. Methods: This was a cross sectional descriptive study of radiologists and medical students using interviews and semi-structured questionnaires respectively. Results: Radiologists' and students' perceptions and opinions on Radiology training were gathered. A Radiology training rationale was developed. Learning outcomes for Radiology were defined and learning formats were chosen. Learning materials were identified and strategies to improve the implementation were formulated. Conclusions: This work has culminated into changes in Radiology integration in the curriculum and training at the FOM

Sonography and risk factors for lower limb deep venous thrombosis at Mulago Hospital, Uganda.

BACKGROUND: Lower limb deep venous thrombosis (DVT), and its sequelae (lower limb chronic venous insufficiency and pulmonary embolism) are now well acknowledged as major haematological problems in the world, for which appropriate and accurate means of diagnosis is necessary. Developments in ultrasound have made it the imaging modality of choice in the diagnosis of lower limb DVT. OBJECTIVES: To determine the sonographic pattern, and identify the risk factors of lower limb DVT. DESIGN: Cross sectional, descriptive study carried out between April 2002 and March 2003. SETTING: Mulago Hospital, Uganda. SUBJECTS: Eighty six consecutive patients (92 limbs), with clinically suspected DVT, were studied by duplex sonography after a thorough risk factor evaluation. RESULTS: Out of a total of 86 patients clinically suspected to have lower limb DVT, 38 (44.2%) were found to have DVT after sonography. The gender incidence was similar. The left limb was affected in 60% of cases and the right in 40%. Bilateral DVT was noted in two patients. Most of the patients had acute and extensive DVT. CONCLUSION: Duplex ultrasonography is a very useful modality for assessing lower limb DVT, even in a low resource country like Uganda. It demonstrates the wealth of information obtained from sonography.

Comparison between sonographic and plain radiography in the diagnosis of small bowel obstruction at Mulago Hospital, Uganda.

OBJECTIVE: To evaluate the role of sonography compared to plain radiography in the diagnosis of patients with suspected small bowel obstruction as well as to determine their specificity, sensitivity and accuracy in the Ugandan setting. DESIGN: Prospective comparative study. SETTING: Mulago Hospital, Uganda's main referal Hospital and Makerere University Medical School. SUBJECTS: Seventy patients with suspected small bowel obstruction (SBO) were evaluated at Mulago Hospital between December 1998 and January 2000, 42 patients were males and 28 females. Patients were aged three days to two years and had a clinical suspicion of SBO. RESULTS: Of the 70 patients, 55 were confirmed to have had SBO. Four had ileus and 11 had no SBO. Sixty four per cent were managed surgically while 36% were managed conservatively. Sonography made a diagnosis of SBO in 92.7% and detected strangulation in 71% of patients. Plain radiography made a diagnosis in 85.5% of patients and did not detect strangulation. Specificity was 100% for both, sensitivity 93%, PPV 100%, NPV 73% for sonography. Sensitivity was 85%, PPV 100%, NPV 58% for plain radiography. MAIN OUTCOME MEASURES: The accuracy of sonography was 93% as compared to 87% for plain radiography. The level of obstruction was correctly predicted in 81% by sonography and 64% with plain radiography. CONCLUSION: It was concluded that sonography is as accurate, specific and sensitive as plain radiography in the diagnosis of SBO as well as determining the level of obstruction in a Ugandan setting. Sonography was found to be more accurate at determining the cause of obstruction and detecting strangulation. It is recommended that sonography should be the initial imaging modality for patients presenting with suspected SBO and plain radiography should only be used as a complimentary investigation.

Serial chest radiographs in the management of children with a clinical suspicion of pulmonary tuberculosis.

The aim of the study was to define the role of serial chest radiographs (SCR) in the management of children with a clinical suspicion of pulmonary tuberculosis (PTB) and to determine the interval at which they should be taken. Eighty children with a clinical suspicion of PTB were studied and followed-up for a duration of 18 months. SCR during the time of treatment were taken at monthly intervals for the first 3 months, then at 2-monthly intervals up to the end of therapy, and finally 2 months post-therapy. These were reviewed and the changes while on treatment noted and correlated with the clinical picture. Lung opacities were observed in 73 children (91 per cent) and were the most common radiological finding on the initial chest X-ray. These were followed by reduced chest wall muscle bulk present in 66 children (83 per cent). Mediastinal and/or hilar lymphadenopathy was noted in 47 children with a significant occurrence in the 0-4 age group (p = 0.004). Pleural effusions, cavities and calcification were rare. Human immunodeficiency virus (HIV) seropositive children with PTB accounted for 87 per cent and carried a poor prognosis (p = 0.0007). The common chest radiographic findings in children with PTB include lung opacities with hilar/mediastinal lymphadenopathy. Pleural effusions, cavitation, calcifications, miliary spread and normal chest X-rays were rare. SCR are useful in monitoring response to treatment, detection of onset of secondary infections and complications. HIV positive patients carry a poor prognosis. Based on the results of this study, pre-treatment, 2 months after onset of treatment, and end of therapy radiographs are recommended as routine in children with a clinical suspicion of PTB.

Disclosure of Imaging findigns to Patients Directly by Radiolgists: A Survey of Patients' Preferences

"The purpose of this study was to determine if patients prefer to hear results of their imaging findings directly from the Radiologist soon after the examination or if they prefer to be told later by their referring clinicians or not to be told at all by either party. Subjects and methods: A simple questionnaire was adminsitered to and answered by 192 consecutive patients seen in the Radiology Department of Mulago Hospital over a 10 day period. These were to udnergo various examinations namely CT; conventional radiography; ultrasound and mammography. Patients were asked if they wanted the Radiologists to disclose results to them or if they would prefer to ehar the results from their referring clinician. Results: Analysis of the 192 questionnaires disclose that 91patients wanted the Radiologist to voluntarily tell them if the results were normal. An additional 1wanted to hear the results but only if they inquired for them. If the results are abnormal (e.g. cancer); 87wanted the Radiologist to voluntarily tell them. An additional 0.5answered ""yes""; but only if they asked for the results. forty one percent (41) preferred to hear the results from their referring clinicians; while 52did not. Conclusion: the prupose of this study was to determine if patients prefer to have Radiologists directly disclose to them their imaging findings immediately after the examination or if they prefer to hear the results later from their referring clinician; regardless of whether the findings are normal or abnormal."

Radiographic appearances of pulmonary tuberculosis in HIV-1 seropositive and seronegative adult patients.

OBJECTIVE: To describe the radiographic pattern of PTB in HIV-1 seropositive and seronegative patients and to study the relationship between radiographic pattern and degree of immunosuppression based on CD4 counts. DESIGN: Cross-sectional, descriptive study. SETTING: TB treatment centre and Department of Radiology, Mulago Referral Hospital and Makerere University Medical Teaching Hospital, Uganda. SUBJECTS: One hundred and fifty consecutive adult patients, suspected on clinical grounds to have PTB. INTERVENTIONS: Three early morning sputum specimens and 10 mls of venous blood taken from each qualifying subject. MAIN OUTCOME MEASURES: Chest x-ray changes and CD4 counts. RESULTS: More than sixty eight per cent of the patients were HIV-1 seropositive. Slightly over seventy two per cent of the seropositives were moderate to severely immunosuppressed, 27.2% were mildly immunosuppressed or had normal immune status. Approximately ninety three per cent of the seronegative individuals had normal immune status or were mildly immunosuppressed, while 6.4% were moderately immunosuppressed. Lung parenchymal opacities were demonstrated in 98.7% of all patients. Intrathoracic lymphadenopathy and cavitation were noted in 43.3% and 41.3% respectively. Fibrosis and pleural effusion were observed in 25.0% and 25.3% respectively. Miliary disease occurred in 2.0%. Seropositives accounted for 81.5% and 76.3% of patients with lymphadenopathy and pleural effusion, 18.5% and 23.7% respectively were seronegative. Seronegatives accounted for 64.9% and 64.5% of those with fibrosis and cavitation respectively, whereas 35.1% 35.5% of fibrosis and cavitation respectively were seropositive. Patients who were moderate to severely immunosuppressed accounted for 64.6% and 63.2% of patients with lymphadenopathy and pleural effusion, 35.4% and 36.8% respectively had normal immune status or were mildly immunosuppressed. Fibrosis and cavitary disease were more frequent in normal or mildly immunosuppressed (78.4% and 72.6%) than in moderately to severely immunosuppressed patients (21.6% and 27.4%) (p<0.001). CONCLUSION: HIV-seropositivity with moderate to severe immunesuppression are associated with atypical radiographic appearances in adult post primary PTB.

Tumoral calcinosis: report of nine cases.

Radiological observations of nine cases of tumoral calcinosis are reported. CT appearances of intracranial lesions in one patient are described. All patients were confirmed by histopathology. After complete excision no recurrence was seen in eight of the patients after a mean follow up of 24 months. Incomplete excision led to recurrence in one case.

Radiological presentation of pulmonary calcinosis: case report.

A 64-year old man presented to the Department of Radiology for evaluation. He had a seven year history of chronic cough. The chest x-ray (CXR) done showed high density diffuse cotton wool parenchymal opacities in both lungs sparing the pleura and broncho vascular bundles. These were also demonstrated on CT. This type of pulmonary calcinosis did not fit in with the classical appearances.

Radiographic Appearances of Pulmonary Tuberculosis in HIV-1 Seropositive and Seronegative Adult Patients

Objective (of this study is): To describe the radiographic pattern of PTB in HIV-1 seropositive and seronegative patients and to study the relationship between radiographic pattern and degree of immunosuppression based on CD4 counts. Design: Cross-sectional; descriptive study. Setting: TB tratment centre and Department of Radiology; Mulago Referral Hospital and Makerere University Medical Teaching Hospital; Uganda. Subjects: One hundred and fiffty consecutive adult patients; suspected on clinical grounds to have TB. Interventions: Three early morning sputum specicimens and 10 mls of venous blood taken from each qualifying subject. Main outcome measures: Chest x-ray changes and CD4 counts. Results: More than sixty eight per cent of the patients were HIV-1 seropositive. Slightly over seventy two per cent of the seropositives were moderate to severely immunosuppresed; 27.2were mildly immunosuppressed; while 6.4were moderately immunosuppressed. Lung parenchymal opacities were demonstrated in 98.7of all patients. Intrathoracic lymphadenopathy and cavitation were noted in 43.3and 41.3respectively. Fibrosis and pleural effusion were observed in 25.0and 25.3respectively. Miliary disease occurred in 2.0. Seropositives accounted for 81.5and 76.3of patients with lymphadenopathy and pleural effusion; 18.5and 23.7respectively were seronegative. Seronegatives accounted for 64.9and 64.5of those with fibrosis and cavitation respectively; whereas 35.135.5of fibrosis and cavitation respectively were seropostive. Patients who were moderate to severely immunosuppressed accounted for 64.6and 63.2of patients with lymphadenopathy and pleural effusion; 35.4and 36.8respectively had normal immune status or were mildly immunosuppressed.Fibrosis and cavitary disease were more frequent in normal or mildly immunosupressed (78.4and 72.6) than in moderately to severely immunosuppressed patients (21.6and 27.4) (p0.001). Conclusion: HIV-seropositivity with moderate to severe immunosuppression are associated with atypical radiographic appearances in adult post primary PTB

Gastric outlet obstruction in Ugandans: a possible ethnic association

Twenty six-adults referred to the Radiology Department; Mulago Hosptial with clinical signs of gastric outlet obstruction were prospectively studied. Relevant demographic data were noted following which the patients underwent a standard upper gastro-intestinal tract (GIT) Barium study in order to define the site; extent and cause of their obstruction. In addition; they underwent endoscopy nad surgery for further diagnostic and therapeutic puposes. Duodenal peptic ulceration was the commonest cause accounting gor obstruction in 19 out of the 26 patients. There was a male to female ratio of 3:2. There was a striking prepondance of patients belonging to the Nkore tribe; a native tribe in Western Uganda. Of the 14 Nkore patient; 12 had obstruction due to chronic duedenal ulceration.. In the majority of patients the obstruction was decompensated or partially compensated. Duodenal ulceration was the usual cause of gastric outlet obstruction and a significant proportion of patients came from Nkore tribe. A larger study to investigate this tribal distribution and to seek specific casual factors and associations is indicated

The frequency of gastric volvulus among patients presenting for upper gastro-intestinal tract Barium studies at Mulago Hospital

Long-standing upper abdominal pain is the commonest symptom in patients referred for upper gastro-intestinal tract (UGIT) Barium studies at the Radiology Department of Mulago Hospital. Between October 1993 and May 1995; 31 patients; attending Mulago Hospital for upper abdominal pain; showed gastric volvulus on UGIT Barium studies. The volvulus was organo-axial in all. It was complete in 10 patients and partial in 21. In 21 patients volvulus was the only finding but 10 had other pathologies such as peptic ulcers; hiatus hernias and gastritis. Symptoms disappeared in all four patients who underwent gastropexy. Important findings at laparotomy were long suspensory ligaments of the stomach and a long transverse mesocolon seen in two patients. In this series; chronic gastric volvulus occurred in 1.2of patients presenting for UGIT studies at Mulago Hospital and may be the cause of pain in some of these individuals

The pattern of computed tomography findings in patients with head injury at Mulago Hospital

Trauma is the commenest indication for surgery of the cranium at Mulago Hospital. Computed tomography (CT) is now widely used as a non invasive method in the investigation of skull trauma and related pathologies. Mulago Hospital has recently acquired a CT Scanner so we set out to evaluate its use in our head injury patients. A retrospective cross-sectional study was carried out on a total of sectional study was carried out on a total of 71 patients. The specific objective of the study was to analyze the pattern of CT findings in head injury patients and to find out how the CT findings influenced the mode of treatment. A standard technique for CT brain scan was employed using a scan plane parallel to the radiographic base line of 5mm contiguous sections through the remainder of administered when pre-contrast scans were not informative. The commonest CT findings were subdural haematoma (41) and intracerebral haemorrhage (32). Twenty seven patients (38) underwent surgery as a result of the CT findings. We have found CT scanning very useful in the management of patients with head injury at Mulago hospital. It clearly defines the pathology; assisting the surgeon in determining the mode of therapy. The pattern of CT findings did not vary from that reported from other radiological and surgical studies

The importance of computed tomography findings in the management of intracranial infections: experince at Mulago Hospital

Mulago Hospital recently acquired a computed tomography (CT) scanner. Intracranial infections arehighly prevalent in third world countries; more so in the AIDS era. CT isa useful non-invasive method of investigating intracranial infections. No data on the value of CT and intracranial infections is available from Uganda and the East African region. We carried out a cross-section descriptive study to evaluate the role of CT in these patients presenting at Mulago Hospital. The specific objectives were to ascertain the frequency ofa various intracranial infections; describe their CT pattern and determine the role of CT in choosing the optimal therapeutic approach. The commonest group of infections were cerebral abscesses (44) which included pyogenic; tuberculous and toxoplasma abscesses; followed by meningitis of variable aetiology (28) and encephalitis (16). CT findings suggestive of pyogenic abscesses and empyaema were invariably an indication for surgery. Appropriate cosnservative therapy was administered in the other patients based on the CT scan together with the relevant clinical and laboratory findings. Theis article illustrates the fact that a good CT characterisation of lesions gives the clinician a working diagnosis on which his therapeutic approach can be based

Congenital diaphragmatic hernia: report of three cases.

Three cases of congenital diaphragmatic hernia (CHD) are presented with special emphasis on a neonate with an unusual combination of abnormalities. It was noted that in all three the hernias were of the Bochdaleck's type. CDH may not always be a single isolated failure of closure of the pleural peritoneal hiatus but a more complex multi organ anomaly.

Bilateral massive galactoceles. An atypical presentation.

Two cases of atypical presentation of galactoceles are reported. Both young women were referred to Mulago Hospital, Department of Radiology for breast imaging because of painful enlargement of both breasts. Both were found to be young lactating mothers. Ultrasound and aspiration was done on both of them. Ultrasound showed cystic lesions in both women. A milky solution was aspirated in both cases.

In vivo and in vitro studies on the sonographical detection of Ascaris lumbricoides.

Intestinal ultrasound, a frequently applied diagnostic tool in industrialized nations, has recently also been introduced in tropical regions. This study attempts to describe the anatomical and sonographical features of Ascaris lumbricoides in the human intestine. In the course of a schistosomiasis morbidity study in Madagascar, 581 inhabitants of a rice-farming village on the high plateau of the island had their stools examined by means of a modified Kato-Katz thick smear technique (four slides per sample); 53% had eggs of Ascaris lumbricoides in their stools. Twenty-two individuals underwent intestinal ultrasound examination and, in six cases, Ascaris lumbricoides was visualized. All six patients showed eggs upon stool examination. At ultrasound, the parasite was seen as a large, curved echogenic strip (4-6 mm in diameter) with an inner, anechoic, longitudinal canal. The image resembled a winding highway, the central structure representing the pseudocoel of the parasite. Patients were treated with mebendazole. The excreted worms of one patient were scanned under water, showing the same characteristics as in vivo. We conclude that Ascaris lumbricoides has a characteristic sonographical appearance and should not be a confounding factor in studies using intestinal ultrasound.