Collaborative task-sharing to enhance the Point-Of-Care Ultrasound (POCUS) access among expectant women in Kenya: The role of midwife sonographers

Unrealized maternal and child health goals continue to challenge Kenya where adverse outcomes remain high and diagnostic services are limited. The acute shortage of doctors and radiographers requires alternate human resources for health (HRH) with the ability to identify risk factors in pregnancy through Point-Of-Care Ultrasound (POCUS). A specialist radiologist and ultrasonography team partnered with midwives to adopt interprofessional task sharing and capacity building. Faculty from the Radiology Department of our hospital designed and implemented the project which was carried out at three outreach health service centres. Designing and implementing a training model to skill midwife sonographers with the capacity to accurately identify risk factors in pregnancy is an effective model to increase POCUS access. A collaborative task sharing model focused on training quality, validation of results, tracking of errors and specialist level clinical supervision yielded a safe and scalable model of HRH capacity building. Programme evaluation, verification of outcomes and dissemination of results were all monitored. The project was a successful HRH task sharing and interprofessional learning initiative involving task sharing a clearly defined suite of sonographer competencies with participating midwives. The programme increased POCUS accessibility at the three outreach clinics with proven outcomes in the early detection and referral of risk factors in pregnancy

Diagnosis of Langerhans Cell Histiocytosis on Fine Needle Aspiration Cytology: A Case Report and Review of the Cytology Literature

A case of multifocal Langerhans cell histiocytosis in a two-year-old child is presented where fine needle aspiration was helpful in achieving a rapid and accurate diagnosis in an appropriate clinical and radiological setting. This can avoid unnecessary biopsy and guide the management especially where access to histopathology is limited. The highly characteristic common and rare cytological features are highlighted with focus on differential diagnoses and causes of pitfalls

The role of inflammation in contrast-induced nephropathy

Objective: Global incidence of contrast-induced nephropathy (CIN) is 2-5%, but a recent Kenyan study highlighted a local incidence of 12-14% without offering an explanation for the higher incidence. This study proposes that inflammatory states confer a higher relative risk for development of CIN. Our objective was to determine the risk of developing CIN given the presence of an inflammatory state in patients in Kenya. Methods: Prospective cohort study of patients undergoing a contrast-enhanced CT (CECT) scan in a private university teaching hospital in Kenya and having no known risk factors for CIN. 423 patients were recruited and grouped into those without inflammation (unexposed) having serum C-reactive protein (CRP) levels ≤5 mg dl(-1) and those with evidence of inflammation having CRP levels \u3e5 mg dl(-1). Serum creatinine (SCr) was measured before the CECT and 48 h following the CECT with CIN diagnosed by an increase of \u3e25% in the SCr from the baseline. Relative risk was determined and multiple logistic regression analysis performed on biophysical variables and contrast volume to assess their effect on development of CIN. Results: Patients with high CRP levels had a relative risk of developing CIN of 2.16 compared with those with normal levels of CRP (p = 0.016). No statistically significant association was seen between biophysical variables or volume of contrast and development of CIN. Conclusion: Ongoing inflammation doubles the likelihood of development of CIN. Advances in knowledge: This study highlights the importance of inflammation as a risk factor in the development of CIN

Training Midwives to Perform Basic Obstetric Point-of-Care Ultrasound in Rural Areas Using a Tablet Platform and Mobile Phone Transmission Technology—A WFUMB COE Project

Point-of-care ultrasound (POCUS) has become a topical subject and can be applied in a variety of ways with differing outcomes. The cost of all diagnostic procedures including obstetric ultrasound examinations is a major factor in the developing world and POCUS is only useful if it can be equated to good outcomes at a lower cost than a routine obstetric examination. The aim of this study was to assess a number of processes including accuracy of images and reports generated by midwives, performance of a tablet-sized ultrasound scanner, training of midwives to complete ultrasounds, teleradiology solution transmissions of images via internet, review of images by a radiologist, communication between midwife and radiologist, use of this technique to identify high-risk patients and improvement of the education and teleradiology model components. The midwives had no previous experience in ultrasound. They were stationed in rural locations where POCUS was available for the first time. After scanning the patients, an interim report was generated by the midwives and sent electronically together with all images to the main hospital for validation. Unique software was used to send lossless images by mobile phone using a modem. Transmission times were short and quality of images transmitted was excellent. All reports were validated by two experienced radiologists in our department and returned to the centers using the same transmission software. The transmission times, quality of scans, quality of reports and other parameters were recorded and monitored. Analysis showed excellent correlation between provisional and validated reports. Reporting accuracy of scans performed by the midwives was 99.63%. Overall flow turnaround time (from patient presentation to validated report) was initially 35 min but reduced to 25 min. The unique mobile phone transmission was faultless and there was no degradation of image quality. We found excellent correlation between final outcomes of the pregnancies and diagnoses on the basis of reports generated by the midwives. Only 1 discrepancy was found in the midwives\u27 reports. Scan results versus actual outcomes revealed 2 discrepancies in the 20 patients identified as high risk. In conclusion, we found that it is valuable to train midwives in POCUS to use an ultrasound tablet device and transmit images and reports via the internet to radiologists for review of accuracy. This focus on the identification of high-risk patients can be valuable in a remote healthcare facility

A Curriculum Model for Multidisciplinary Training of Midwife Sonographers in a Low Resource Setting

In many low-resource settings, less than 5% of pregnant women can access ultrasound during pregnancy. Thus, gestational age is often difficult to determine, multiple pregnancies are diagnosed late and foetal and pregnancy-related anomalies can go undetected. A pilot solution was designed beyond the traditional approach of increasing numbers of qualified radiologists, gynaecologists and sonographers. An innovative Human Resource for Health (HRH) task sharing, and maternal child health (MCH) workforce training and capacity building initiative was designed, involving development and testing of a curriculum to train midwife sonographers via a teleradiology innovation platform and a partnership between specialist radiologists, sonographers and midwives. The setting was a tertiary-level private university hospital in Nairobi with implementation in three outreach locations. Direct oversight, support and supervision of specialist radiologists and ultrasonographers effectively addressed issues of quality and safety across the 3-week training period and project implementation. Concepts from sociocultural learning theory informed an initial interactive e-learning module for each midwife at their respective site. Midwives were introduced to ultrasound equipment with a series of didactic and interactive lectures delivered by an expert sonographer at the tertiary hospital teaching site. Lectures were supported by hands-on practical experience, role modelling and mentoring over a four-week period. Assessments included both written examination and practical assessment with an exit examination requiring demonstration of competency in both written and practical format. Final confirmation of scanning accuracy was confirmed with post-delivery verification of results. The pilot was highly successful with an image interpretation accuracy of 99.63% for the midwives. Lessons from this initiative provides guidance in the curriculum development process along with a curriculum outline; pedagogical framework; teaching methods; assessment processes; credentialing; resourcing; and other considerations in scaling up the program. Importantly, the paper details processes for maintaining a high level of quality control and patient safety

Uterine fibroid embolization for symptomatic fibroids: study at a teaching hospital in Kenya

Objective: Characterization of magnetic (MRI) features in women undergoing uterine fibroid embolization (UFE) and identification of clinical correlates in an African population. Materials and Methods: Patients with symptomatic fibroids who are selected to undergo UFE at the hospital formed the study population. The baseline MRI features, baseline symptom score, short-term imaging outcome, and mid-term symptom scores were analyzed for interval changes. Assessment of potential associations between short-term imaging features and mid-term symptom scores was also done. Results: UFE resulted in statistically significant reduction (P \u3c 0.001) of dominant fibroid, uterine volumes, and reduction of symptom severity scores, which were 43.7%, 40.1%, and 37.8%, respectively. Also, 59% of respondents had more than 10 fibroids. The predominant location of the dominant fibroid was intramural. No statistically significant association was found between clinical and radiological outcome. Conclusion: The response of uterine fibroids to embolization in the African population is not different from the findings reported in other studies from the west. The presence of multiple and large fibroids in this study is consistent with the case mix described in other studies of African-American populations. Patient counseling should emphasize the independence of volume reduction and symptom improvement. Though volume changes are of relevance for the radiologist in understanding the evolution of the condition and identifying potential technical treatment failures, it should not be the main basis of evaluation of treatment success

High Prevalence of Liver Fibrosis in Patients with Human Immunodeficiency Virus Monoinfection and Human Immunodeficiency Virus Hepatitis-B Co-infection as Assessed by Shear Wave Elastography: Study at a Teaching Hospital in Kenya

Objectives:The aim of this study was to determine the prevalence of liver fibrosis in patients with human immunodeficiency virus (HIV) monoinfection versus those with HIV hepatitis-B virus (HBV) co-infection as assessed with shear wave elastography (SWE) in a tertiary sub-Saharan Africa hospital. Materials and Methods:A total of 105 consecutive patients, 70 with HIV monoinfection and 35 with HIV-HBV co-infection, had liver elastography obtained using SWE to assess for the presence of liver fibrosis the cutoff of which was 5.6 kPa. Assessment of aspartate aminotransferase-to-platelet ratio index (APRI) score (a noninvasive serum biomarker of liver fibrosis) in these patients was also done. Results:The prevalence of liver fibrosis was significantly higher (P \u3c 0.0001) in patients with HIV-HBV co-infection, 25.7%, compared to those with HIV monoinfection, 7.1%. APRI score was greater in patients with HIV-HBV co-infection than those with HIV monoinfection. HIV co-infection with HBV accelerates progression to liver fibrosis. Association of a low cluster of differentiation 4 (CD-4) count with advanced fibrosis supports earlier starting of antiretroviral therapy to prevent rapid progression of liver disease in HIV-positive patients. Conclusion:In view of the high prevalence of liver fibrosis in patients with HIV-HBV co-infection, regular monitoring of the disease progression is recommended

Ultrasound shear wave elastography and liver fibrosis: A Prospective Multicenter Study

Aim: To assess the accuracy of shear wave elastography (SWE) alone and in combination with aminotransferase platelet ratio index (APRI) score in the staging of liver fibrosis. Methods: A multicenter prospective study was conducted to assess the accuracy of SWE (medians) and APRI to predict biopsy results. The analysis focused on distinguishing the different stages of liver disease, namely, F0 from F1-4, F0-1 from F2-4, F0-2 from F3-4 and F0-3 from F4; F0-F1 from F2-F4 being of primary interest. The area under the receiver operating characteristic (AUROC) curve was computed using logistic regression model. The role of age, gender and steatosis was also assessed. Results: SWE alone accurately distinguished F0-1 from F2-4 with a high probability. The AUROC using SWE alone was 0.91 compared to 0.78 for using the APRI score alone. The APRI score, when used in conjunction with SWE, did not make a significant contribution to the AUROC. SWE and steatosis were the only significant predictors that differentiated F0-1 from F2-4 with an AUROC of 0.944. Conclusion: Our study validates the use of SWE in the diagnosis and staging of liver fibrosis. Furthermore, the probability of a correct diagnosis is significantly enhanced with the addition of steatosis as a prognostic factor

Utility of Multiparametric Magnetic Resonance Imaging as a Predictor of Clinically Significant Prostate Cancer in a Sub-Saharan African Population

Background: Traditionally, the diagnosis of prostate cancer was based on increased prostate-specific antigen level or an abnormal digital rectal examination and confirmed histologically following biopsy. Consequently, a proportion of men without cancer or with clinically insignificant disease undergo unwarranted prostate biopsies and experience resultant complications. Pre-biopsy multiparametric magnetic resonance imaging (MP-MRI) is vital in determining those with clinically significant cancer who need biopsy and those with a negative MRI who can safely avoid unnecessary biopsy. Methods: The diagnostic accuracy of MP-MRI using transrectal ultrasound-guided biopsy as the reference test was established for 133 men who had undergone MRI and biopsy. The MRI images were reviewed and reported by two independent consultant radiologists. Clinically significant cancer was defined as Prostate Imaging Reporting and Data System score ≥3 on multiparametric MRI and Gleason score ≥3 + 4 (grade group ≥2) on histology. Results: MP-MRI of the prostate was found to have 92% sensitivity, 47.8% specificity, 86.8% negative predictive value (NPV) and 62% positive predictive value for the diagnosis of prostate cancer. Conclusion: MP-MRI has a high sensitivity and a high NPV, validating its use in pre-biopsy evaluation of men at risk of prostate cancer to safely avoid unnecessary prostate biopsy and to guide biopsy of suspicious lesions

CardiOvaScular Mechanisms In Covid-19: methodology of a prospective observational multimodality imaging study (COSMIC-19 study)

Background: 8-28% of patients infected with COVID-19 have evidence of cardiac injury, and this is associated with an adverse prognosis. The cardiovascular mechanisms of injury are poorly understood and speculative. We aim to use multimodality cardiac imaging including cardiac magnetic resonance (CMR) imaging, computed tomography coronary angiography (CTCA) and positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro- D-glucose integrated with computed tomography (18F-FDG-PET/CT) to identify the cardiac pathophysiological mechanisms related to COVID-19 infections. Methods: This is a single-centre exploratory observational study aiming to recruit 50 patients with COVID-19 infection who will undergo cardiac biomarker sampling. Of these, 30 patients will undergo combined CTCA & 18F-FDG-PET/CT, followed by CMR. Prevalence of obstructive and non-obstructive atherosclerotic coronary disease will be assessed using CTCA. CMR will be used to identify and characterise myocardial disease including presence of cardiac dysfunction, myocardial fibrosis, myocardial oedema and myocardial infarction. 18F-FDG-PET/CT will identify vascular and cardiac inflammation. Primary endpoint will be the presence of cardiovascular pathology and the association with troponin levels. Discussion: The results of the study will identify the presence and modality of cardiac injury associated COVID-19 infection, and the utility of multi-modality imaging in diagnosing such injury. This will further inform clinical decision making during the pandemic