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

Antenatal Doppler ultrasound implementation in a rural sub-Saharan African setting: exploring the perspectives of women and healthcare providers.

BACKGROUND: The World Health Organization recommends research to evaluate the effects of a single third trimester Doppler ultrasound examination on preventable deaths in unselected-risk pregnancies, particularly in low- and middle-income countries (LMICs) where the evidence base is scarce. While evaluating such technologies, researchers often ignore women and health care provider perspectives. This study explored the views and experiences of women and healthcare providers regarding the use of advanced ultrasound technology to optimize the health of mothers and their babies in a rural community in mid-western Uganda. METHODS: We enrolled 53 mothers and 10 healthcare providers, and captured data on their perceptions, barriers, and facilitators to the use of Doppler ultrasound technology using focus group discussions, semi-structured interviews and observations. Using qualitative content analysis, we inductively coded the transcripts in ATLAS.ti 8.0, detecting emerging themes. RESULTS: Women were afraid that ultrasound would harm them or their fetuses and many of them had never seen an ultrasound scan. The majority of the women found their partners supportive to attend antenatal care and use ultrasound services. Healthcare providers in Kagadi Hospital were unfamiliar with Doppler technology and using it to guide clinical decisions. Other barriers to the implementation of Doppler ultrasound included shortage of trained local staff, insufficient equipment, long distance to and from the hospital, and frequent power cuts. CONCLUSIONS: We found limited exposure to Doppler ultrasound technology among women and healthcare providers in mid-western Uganda. Engaging male partners may potentially influence the likelihood of accepting and using it to improve the health of women and their fetuses while wide spread myths and misconceptions about it may be changed by community engagement. Healthcare workers experienced difficulties in offering follow-up care to mothers detected with complications and Doppler ultrasound required a high level of training. While introducing advanced ultrasound machines to weak health systems, it is important to adequately train healthcare providers to avoid inappropriate interventions based on misinterpretation of the findings, consider where it is likely to be most beneficial, and embed it with realistic clinical practice guidelines

Prognostic accuracy of antenatal Doppler ultrasound for adverse perinatal outcomes in low-income and middle-income countries: a systematic review.

OBJECTIVES: This systematic review examined available literature on the prognostic accuracy of Doppler ultrasound for adverse perinatal outcomes in low/middle-income countries (LMIC). DESIGN: We searched PubMed, Embase, Cochrane Library and Scopus from inception to April 2020. SETTING: Observational or interventional studies from LMICs. PARTICIPANTS: Singleton pregnancies of any risk profile. INTERVENTIONS: Umbilical artery (UA), middle cerebral artery (MCA), cerebroplacental ratio (CPR), uterine artery (UtA), fetal descending aorta (FDA), ductus venosus, umbilical vein and inferior vena cava. PRIMARY AND SECONDARY OUTCOME MEASURES: Perinatal death, stillbirth, neonatal death, expedited delivery for fetal distress, meconium-stained amniotic fluid, low birth weight, fetal growth restriction, admission to neonatal intensive care unit, neonatal acidosis, Apgar scores, preterm birth, fetal anaemia, respiratory distress syndrome, length of hospital stay, birth asphyxia and composite adverse perinatal outcomes (CAPO). RESULTS: We identified 2825 records, and 30 (including 4977 women) from Africa (40.0%, n=12), Asia (56.7%, n=17) and South America (3.3%, n=01) were included. Many individual studies reported associations and promising predictive values of UA Doppler for various adverse perinatal outcomes mostly in high-risk pregnancies, and moderate to high predictive values of MCA, CPR and UtA Dopplers for CAPO. A few studies suggested that the MCA and FDA may be potent predictors of fetal anaemia. No randomised clinical trial (RCT) was found. Most studies were of suboptimal quality, poorly powered and characterised by wide variations in outcome classifications, the timing for the Doppler tests and study populations. CONCLUSION: Local evidence to guide how antenatal Doppler ultrasound should be used in LMIC is lacking. Well-designed studies, preferably RCTs, are required. Standardisation of practice and classification of perinatal outcomes across countries, following the international standards, is imperative. PROSPERO REGISTRATION NUMBER: CRD42019128546

Middle cerebral arterial flow redistribution is an indicator for intrauterine fetal compromise in late pregnancy in low-resource settings: A prospective cohort study.

OBJECTIVE: We aimed to determine the prevalence of abnormal umbilical artery (UA), uterine artery (UtA), middle cerebral artery (MCA) and cerebroplacental ratio (CPR) Doppler, and their relationship with adverse perinatal outcomes in women undergoing routine antenatal care in the third trimester. DESIGN: Prospective cohort. SETTING: Kagadi Hospital, Uganda. POPULATION: Non-anomalous singleton pregnancies. METHODS: Women underwent an early dating ultrasound and a third-trimester Doppler scan between 32 and 40 weeks of gestation, from 2018 to 2020. We handled missing data using multiple imputation and analysed the data using descriptive methods and a binary logistic regression model. MAIN OUTCOME MEASURES: Composite adverse perinatal outcome (CAPO), perinatal death and stillbirth. RESULTS: We included 995 women. The mean gestational age at Doppler scan was 36.9 weeks (SD 1.02 weeks) and 88.9% of the women gave birth in a health facility. About 4.4% and 5.6% of the UA pulsatility index (PI) and UtA PI were above the 95th percentile, whereas 16.4% and 10.4% of the MCA PI and CPR were below the fifth percentile, respectively. Low CPR was strongly associated with stillbirth (OR 4.82, 95% CI 1.09-21.30). CPR and MCA PI below the fifth percentile were independently associated with CAPO; the association with MCA PI was stronger in small-for-gestational-age neonates (OR 3.75, 95% CI 1.18-11.88). CONCLUSION: In late gestation, abnormal UA PI was rare. Fetuses with cerebral blood flow redistribution were at increased risk of stillbirth and perinatal complications. Further studies examining the predictive accuracy and effectiveness of antenatal Doppler ultrasound screening in reducing the risk of perinatal deaths in low- and middle-income countries are warranted. TWEETABLE ABSTRACT: Blood flow redistribution to the fetal brain is strongly associated with stillbirths in low-resource settings

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

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. The East African Medical Journal Vol. 83(8) 2006: 443-44

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

ObjectiveWe 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.MethodsConsecutive 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.ResultsSmear 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).ConclusionAlthough 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