Analysis of licensed South African diagnostic imaging equipment

Evaluation of radiological capacity and usage in paediatric TB diagnosis: A mixed-method protocol of a comparative study in Mozambique, South Africa and Spain

INTRODUCTION

Tuberculosis remains one of the top ten causes of mortality globally. Children accounted for 12% of all TB cases and 18% of all TB deaths in 2022. Paediatric TB is difficult to diagnose with conventional laboratory tests, and chest radiographs remain crucial. However, in low-and middle-income countries with high TB burden, the capacity for radiological diagnosis of paediatric TB is rarely documented and data on the associated radiation exposure limited.

METHODS

A multicentre, mixed-methods study is proposed in three countries, Mozambique, South Africa and Spain. At the national level, official registry databases will be utilised to retrospectively compile an inventory of licensed imaging resources (mainly X-ray and Computed Tomography (CT) scan equipment) for the year 2021. At the selected health facility level, three descriptive cross-sectional standardised surveys will be conducted to assess radiology capacity, radiological imaging diagnostic use for paediatric TB diagnosis, and radiation protection optimization: a site survey, a clinician-targeted survey, and a radiology staff-targeted survey, respectively. At the patient level, potential dose optimisation will be assessed for children under 16 years of age who were diagnosed and treated for TB in selected sites in each country. For this component, a retrospective analysis of dosimetry will be performed on TB and radiology data routinely collected at the respective sites. National inventory data will be presented as the number of units per million people by modality, region and country. Descriptive analyses will be conducted on survey data, including the demographic, clinical and programmatic characteristics of children treated for TB who had imaging examinations (chest X-ray (CXR) and/or CT scan). Dose exposure analysis will be performed by children's age, gender and disease spectrum.

DISCUSSION

As far as we know, this is the first multicentre and multi-national study to compare radiological capacity, radiation protection optimization and practices between high and low TB burden settings in the context of childhood TB management. The planned comparative analyses will inform policy-makers of existing radiological capacity and deficiencies, allowing better resource prioritisation. It will inform clinicians and radiologists on best practices and means to optimise the use of radiological technology in paediatric TB management.

Cost of Low-Value Imaging Worldwide: A Systematic Review

BACKGROUND AND OBJECTIVE

Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide.

METHODS

This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive.

RESULTS

Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients.

CONCLUSIONS

This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.

A Case Report on the Diagnosis of Acute Abdominal Aortic Occlusion Using Point-of-Care Ultrasound in the Emergency Department

Point-of-care ultrasound (PoCUS) can be used to detect and evaluate for an aneurysm and/or a dissection of the abdominal aorta in suspected patients in the Emergency Department (ED). Despite the routine use of PoCUS for the assessment of the abdominal aorta in suspected aortic aneurysms and dissections, there is limited literature regarding its use in the diagnosis of acute abdominal aortic occlusions in the emergency setting. This is a case demonstrating the use of PoCUS in identifying an acute aortic occlusion in a 71-year-old female patient with known hypertension and diabetes mellitus. The patient presented with central abdominal pain and bilateral lower limb weakness to the ED. The patient had multiple differential diagnoses, including a possible acute aortic occlusion of the abdominal aorta. PoCUS of the aorta was utilized to diagnose an acute abdominal aortic occlusion in the ED. The rapid diagnosis expedited the referral to vascular surgeons for definitive management. Acute abdominal aortic occlusion is a time-sensitive and life-threatening emergency. PoCUS of the abdominal aorta to detect acute abdominal occlusions allows for a rapid diagnosis with the potential to improve outcomes. A protocol for detecting acute abdominal aortic occlusion should be included in the standard aorta PoCUS scan.

Comparison of chest radiograph findings in ambulatory and hospitalized children with pulmonary tuberculosis

BACKGROUND

The diagnosis of childhood tuberculosis (TB) is, in many instances, solely reliant on chest radiographs (CXRs), as they are often the only diagnostic tool available, especially in TB-endemic areas. Accuracy and reliability of CXRs for detecting TB lymphadenopathy may vary between groups depending on severity of presentation and presence of parenchymal disease, which may obscure visualization.

OBJECTIVE

To compare CXR findings in ambulatory versus hospitalized children with laboratory confirmed pulmonary TB versus other lower respiratory tract infections (LRTI) and test inter-rater agreement for these findings.

MATERIALS AND METHODS

Retrospective review, by two pediatric radiologists, of CXRs performed on children < 12 years old referred for evaluation of LRTI with clinical suspicion of pulmonary TB in inpatient and outpatient settings. Each radiologist commented on imaging findings of parenchymal changes, lymphadenopathy, airway compression and pleural effusion. Frequency of imaging findings was compared between patients based on location and diagnosis and inter-rater agreement was determined. Accuracy of radiographic diagnosis was compared to laboratory testing which served as the gold standard.

RESULTS

The number of enrolled patients was 181 (54% males); 69 (38%) were ambulatory and 112 (62%) were hospitalized. Of those enrolled, 87 (48%) were confirmed to have pulmonary TB, while 94 (52%) were other LRTI controls. Lymphadenopathy and airway compression were more common in TB patients than other LRTI controls, regardless of patient location. Parenchymal changes and pleural effusion were more common in hospitalized than ambulatory patients, regardless of patient diagnosis. Agreement for parenchymal changes was higher in the hospitalized group (kappa [κ] = 0.75), while agreement for lymphadenopathy (κ = 0.65) and airway compression (κ = 0.68) was higher in the ambulatory group. The specificity of CXRs for TB diagnosis (> 75%) was higher than the sensitivity (< 50%) for both ambulatory and hospitalized groups.

CONCLUSION

Higher frequency of parenchymal changes among hospitalized children may conceal specific imaging findings of TB such as lymphadenopathy, contributing to the poor reliability of CXRs. Despite this, the high specificity of CXRs shown in our results is encouraging for continued use of radiographs for TB diagnosis in both settings.

Challenges in the diagnosis and management of IBD: a sub-Saharan African perspective

With the exception of South Africa, inflammatory bowel disease (IBD) has long been considered uncommon in sub-Saharan Africa (SSA) with a dearth of peer-reviewed publications from the subcontinent. This most likely reflects underreporting as some cases may be missed due to the high burden of infectious diseases which may closely mimic IBD. In addition, many countries in SSA have limited endoscopic capacity, inadequate access to diagnostic imaging and a notable scarcity of histopathologists, radiologists and gastroenterologists. Beyond these obstacles, which significantly impact patient care, there are many other challenges in SSA, particularly the unavailability of key IBD therapies. In this review, we discuss barriers in diagnosing and managing IBD in SSA, as well as some of the initiatives currently in place to address these short comings.

Radiation Protection among South African Diagnostic Radiographers-A Mixed Method Study

ABSTRACT

Worldwide, radiographers' radiation protection practices vary. In South Africa, evidence of diagnostic radiographers' suboptimal radiation protection practices has been reported, but the reasons for these practices and suggestions to improve practices were lacking. Therefore, this study explored radiation protection among South African diagnostic radiographers. This study used an explanatory, sequential, mixed-method approach. Data were collected in three phases. Phase I, the quantitative phase, used an online questionnaire and respondents from Phase I interested in participating in Phase II, the qualitative phase, were interviewed, yielding 13 in-depth semi-structured telephone interviews. In Phase III, eight radiography managers co-constructed change strategies to optimize radiation protection in South Africa in two focus group interviews. Radiation protection was suboptimal despite diagnostic radiographers having a good attitude, subjective norm and perceived behavioral control toward radiation protection and optimal radiation protection knowledge. Varying attitudes to radiation protection, lack of resources, and support from radiography management and healthcare teams contributed to suboptimal radiation protection practices. Radiography managers suggested increasing radiation protection awareness, ameliorating the diminished stature of the radiographer in the healthcare team, and increasing the availability of optimal quality resources. South African diagnostic radiographers' radiation protection knowledge was optimal, but the implementation of radiation protection varied and was influenced by multiple factors. A radiation protection culture supported by management is advocated to optimize radiation protection. However, ultimately radiation protection practices are incumbent on the individual radiographers' choice to practice radiation protection.

CT Utilization in a Level One Trauma Center in South Africa

Introduction

Computed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging.

Methods

This was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department’s picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate.

Results

There were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan.

Conclusions

South Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting. 

After-hour trauma-radiograph interpretation in the emergency centre of a District Hospital

Introduction

Plain radiographs remain a first-line trauma investigation. Most trauma radiographs worldwide are reported by junior doctors. This study assesses the accuracy of after-hour acute trauma radiograph reporting by emergency centre (EC) doctors in an African district hospital.

Methods

An institutional review board approved retrospective descriptive study over two consecutive weekends in February 2020. The radiologist report on the admission radiographs of adult trauma patients was compared with the initial EC interpretation. The accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for EC interpretation were calculated with 95% confidence intervals (95%CI). The association between reporting accuracy and anatomical region, mechanism of injury, time of investigation, and the number of abnormalities per radiograph was assessed.

Results

140 radiographs were included, of which 49 (35%) were abnormal. EC doctors recorded (95%CI) 77% (69-84%) accuracy, 38% (25-54%) sensitivity, 97% (91-99%) specificity, 86% (65-95%) PPV and 76% (71-80%) NPV. Performance was associated with the anatomical region (p=0.02), mechanism of injury (p=<0.01) time of day (p=0.04) and the number of abnormalities on the film (p=<0.01). The highest sensitivity was achieved in reports of the appendicular skeleton (42%) and in the setting of simple blunt trauma (62%). Overall accuracy was in line with the range (44%-99%) reported in the international literature.

Discussion

Accurate reporting of acute trauma radiographs is challenging. Key factors impact performance. Further training of junior doctors in this area of clinical practice is recommended. Future work should focus on assessing the impact of such training on reporting performance.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review

Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings

A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Summary

Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Medical physics services in radiology and nuclear medicine in Africa: challenges and opportunities identified through workforce and infrastructure surveys

The International Atomic Energy Agency (IAEA) developed a staffing model to estimate the number of clinically qualified medical physicists (CQMP) that are required in an imaging facility, including diagnostic radiology and nuclear medicine. For the first time this staffing model was applied on a large scale across Africa. Within the framework of the IAEA African Regional Agreement (AFRA) Technical Cooperation (TC) project RAF6/053 entitled “Enhancing Capacity Building of Medical Physics to Improve Safety and Effectiveness of Medical Imaging (AFRA)”, a survey based on the IAEA staffing model was used to investigate the current CQMP workforce needs in imaging and radionuclide therapy in Africa in order to establish a baseline, identify gaps and suggest steps for improvement. The survey was open for five months, after which data verification was performed. 82 responses were received from 21 countries, including data from 97 diagnostic radiology and 40 nuclear medicine departments, as well as 75 interventional radiology departments and/or catheterization laboratories. Only 26·8% of centres employed an adequate number of CQMPs. The staffing model indicated that 134·3 CQMPs were required for these centres, but only 63 are currently employed in medical imaging and/or nuclear medicine at these centres. At least 11 countries do not have a single institution with an adequate number of CQMPs. Data analysis indicated that the number of radiology and nuclear medicine CQMPs is largely inadequate, at least by a factor of 20 in almost all countries in the region.

Subjective symptoms of SMFs and RF energy, and risk perception among staff working with MR scanners within two public hospitals in South Africa

This study assessed subjective symptoms associated with exposure to static magnetic fields (SMFs) and radiofrequency (RF) energy, and perceived safety risk of scanners among magnetic resonance (MR) staff working in the 1.5 and 3 T MRI units. A questionnaire survey was completed by 77 clinical imaging staff working in two hospitals (A and B) in the Mangaung metropolitan region. 50 participants working with the MR scanners were regarded as exposed group and 27 participants from CT scan and X-ray departments were classified as control group. The study comprised 57% females and 43% male participants with an average MRI experience of 5.4 years. Using logistic regression, tinnitus was significantly different between various job titles (p< .034) and it was reported more often (OR 8:00; CI 1.51, 15.17) by those who worked on a 3 T scanner. Increased years of MRI experience was a significant predictor of headache (p< .05), and reporting of nausea was significantly different between various job titles (p < .01). There was an increased risks of reporting vertigo often among female participants (OR: 4.43; CI 0.91, 21.47), those with 5-15 years of MRI experience (OR: 2.09; CI 0.47, 9.34), and those with a light to moderate workload (OR: 2.70; CI 0.49, 14.86). Using linear regression, presence in zone IV during image acquisitioning was the only significant predictor for the sensation of glowing (p < .000). Movement of head/ upper body in the scanner bore was a significant predictor of nausea (p< .026), vertigo (p< .014), instability when standing (p< .014), and a metallic taste (p< .031). There was no correlation between reporting of symptoms and perceived risk of scanners. However, shift duration (r_s = 0.576), movement of head/upper body in the scanner bore (r_s = 0.424), and strength of the scanners (r_s = 0.299) were significantly correlated with perceived risk of scanners. MRI safety training and a comprehensive occupational health and safety program are necessary.

Trends in public sector radiological usage in the Western Cape Province, South Africa: 2009-2019

Background

Although global use of medical imaging has increased significantly, little is known about utilisation trends in low- and middle-income countries (LMICs).

Objectives

To evaluate changes over a decade in public sector diagnostic imaging utilisation at provincial level in a middle-income country.

Method

A retrospective analysis of medical imaging utilisation in the Western Cape Province of South Africa in 2009 and 2019. Use of conventional radiography, ultrasonography (US), fluoroscopy, CT, MRI, digital subtraction angiography (DSA) and whole-body digital radiography was assessed by total studies and studies/10³ people, for the whole province, the rural and metropolitan areas. Mammography utilisation was calculated for every 10³ females aged 40–70 years.

Results

The provincial population and total imaging investigations increased by 25% and 32%, respectively, whilst studies/10³ people increased by 5.5% (256 vs 270/10³), with marked variation by modality. Provincial US, CT and MRI utilisation/10³ people increased by 111% (20 vs 43/10³), 78% (10 vs 18/10³) and 32% (1.9 vs 2.5/10³) respectively, whilst use of fluoroscopy (3.6 vs 3.7/10³) and mammography (14.2 vs 15.9/10³ women aged 40–70 years) was steady and plain radiography decreased by 20% (216 vs 196/10³). For CT, mammography and fluoroscopy, percentage utilisation increases/10³ people were higher in the rural than metropolitan areas.

Conclusion

Population growth is the main driver of overall imaging utilisation in our setting. The relatively constant imaging workload per 1000 people, albeit with increasing ultrasound, CT and MR utilisation, and decreasing use of plain radiography, reflects improved provincial imaging infrastructure, and appropriate use of available resources.

Analysis of registered radiological equipment in Kenya

INTRODUCTION

diagnostic radiology plays a key role in healthcare. Proper planning of healthcare requires accurate and robust data. There´s, however, paucity of comprehensive figures on radiological equipment in the African setting. The goal of this study was to carry out an in-depth analysis of the registered radiological equipment in Kenya, a lower middle-income African country, and compare the findings to published international data.

METHODS

data on radiological equipment were obtained from the Kenya Nuclear Regulatory Authority and analyzed as units/million of the population by imaging modality, health service sector and administrative units. The findings were then compared to published international data.

RESULTS

there has been an overall increase in the number of radiological equipment in comparison to data published in 2013, with a relatively uniform distribution of resources across all eight regions. General radiography is the most available modality at 24.5 units/million with the majority of the equipment owned privately, while the public sector (9.6 units/million) has less than a half of the WHO recommendation of 20 units/million. Accessibility to computerized tomography (CT) scan, fluoroscopy and mammography in the public sector closely mirrors that of South Africa. On the contrary, positron emission tomography-computerized tomography (PET-CT) is the least-resourced modality and is currently only available in the private sector.

CONCLUSION

the increased number and homogenous distribution of radiological resources can largely be attributed to the Managed Equipment Services project launched by the national government in 2016. More needs to be done with regards to availability of PET/CT scanners and general radiography equipment in the public sector.

Towards equity: a retrospective analysis of public sector radiological resources and utilization patterns in the metropolitan and rural areas of the Western Cape Province of South Africa in 2017

Background

The reduction of inequality is a key United Nations 2030 Sustainable Development Goal (WHO, Human Resources for Health: foundation for Universal Health Coverage and the post-2015 development agenda, 2014; Transforming our world: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform, 2020). Despite marked disparities in radiological services globally, particularly between metropolitan and rural populations in low- and middle-income countries, there has been little work on imaging resources and utilization patterns in any setting (Transforming our world: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform, 2020; WHO, Local Production and Technology Transfer to Increase Access to Medical Devices, 2019; European Society of Radiology (ESR), Insights Imaging 6:573-7, 2015; Maboreke et al., An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity, 2020; Kabongo et al., Pan Afr Med J 22, 2015; Skedgel et al., Med Decis Making 35:94-105, 2015; Mollura et al., J Am Coll Radiol 913-9, 2014; Culp et al., J Am Coll Radiol 12:475-80, 2015; Mbewe et al., An audit of licenced Zambian diagnostic imaging equipment and personnel, 2020). To achieve equity, a better understanding of the integral components of the so called “imaging enterprise” is important. The aim was to analyse a provincial radiological service in a middle-income country.

Methods

An institutional review board-approved retrospective audit of radiological data for the public healthcare sector of the Western Cape Province of South Africa for 2017, utilizing provincial databases.

We conducted population-based analyses of imaging equipment, personnel, and service utilization data for the whole province, the metropolitan and the rural areas.

Results

Metropolitan population density exceeds rural by a factor of ninety (1682 vs 19 people/km²). Rural imaging facilities by population are double the metropolitan (20 vs 11/10⁶ people). Metropolitan imaging personnel by population (112 vs 53/10⁶ people) and equipment unit (1.7 vs 0.7/unit) are more than double the rural. Overall population-based utilization of imaging services was 30% higher in the metropole (289 vs 214 studies/10³ people), with mammography (24 vs 5 studies/10³ woman > 40 years) and CT (21 vs 6/10³ people) recording the highest, and plain radiography (203 vs 171/10³ people) the lowest differences.

Conclusion

Despite attempts to achieve imaging equity through the provision of increased facilities/million people in the rural areas, differential utilization patterns persist.

The achievement of equity must be seen as a process involving incremental improvements and iterative analyses that define progress towards the goal.

An audit of Zimbabwean public sector diagnostic ultrasound services

Introduction

the provision of basic diagnostic imaging services is pivotal to achieving universal health coverage. An estimated two-thirds of the world's population have no access to basic diagnostic imaging. Accurate data on current imaging equipment resources are required to inform health delivery strategy and policy at national level. This is an audit of Zimbabwean public sector diagnostic ultrasound resources and services.

Methods

utilising the Ministry of Health and Child Care (MHCC) database, sequential interviews were conducted with provincial health authorities and local facility managers. Ultrasound equipment, personnel and services in all hospitals and clinics, nationally were recorded, collated, and analysed for the whole country, and by province.

Results

of the 1798 Zimbabwean public sector healthcare facilities, sixty-six (n=66, 3.67%) have ultrasound equipment. Ninety-nine (n=99) ultrasound units are distributed across the sonar facilities, representing a national average of 8 units per million people. More than half the equipment units (n=53, 54%) are in secondary-level healthcare facilities (district and mission hospitals), and approximately one-fifth (n=22, 22%) in the central hospitals (quaternary level). The best-resourced province has twice the resources of the least resourced. One-hundred and forty-two (n=142) healthcare workers, from six different professional groups, provide the public sector ultrasound service. Most facilities with sonar equipment (n=64/66, 97%) provide obstetrics and gynaecology services, while general abdominal scanning is available at one third (n=22, 33%). Two facilities with ultrasound equipment have no capacity to offer a sonography service.

Conclusion

in order to reach the WHO recommendation of 20 sonar units per million people, an estimated 140 additional sonar units are required nationally. The need is greatest in Masvingo, Midlands and Mashonaland East Provinces. Task-shifting plays a key role in the provision of Zimbabwean sonar services. Consideration should be given to formal training and accreditation of all healthcare workers involved in sonar service delivery.

Using the theory of planned behaviour to determine radiation protection among South African diagnostic radiographers: a cross-sectional survey

Introduction

The use of ionising radiation in medicine accounts for the majority of radiation exposure from artificial sources. Therefore, all measures to safeguard against unnecessary radiation exposure must be taken. As radiographers are central to radiation protection, this study aimed to determine South African radiographers’ attitude towards radiation protection, subjective norm and perceived behavioural control concerning radiation protection.

Methods

This quantitative cross‐sectional study used an online theory of a planned behaviour radiation protection questionnaire shared through social media platforms from August 2019 to February 2020. Diagnostic radiographers registered with the Health Professions Council of South Africa and employed at radiology departments in South Africa were invited to participate in the study.

Results

Four hundred and seventeen radiographers in South Africa responded to the questionnaire. The majority of respondents (90%, n = 376) plan to use radiation protection; however, only 16% continuously used radiation protection in the past. Respondents felt that using radiation protection was extremely good (72.2%), pleasant (47%), beneficial (74.1%), rewarding (55.2%) and worth the time (52.5%); 57% of respondents indicated that using radiation protection takes longer to complete the examination. Respondents report that approval from patients (43.5%), patients’ family (32%), radiographer coworkers (31%), radiology managers (47%) and radiologists (43.9%) is very much important to them.

Conclusion

The study shows that even though fewer respondents use radiation protection at present, most respondents plan and intend to use radiation protection measures. Respondents felt that radiation protection was good and beneficial, with some respondents feeling that radiation protection is not worth the time, which coincide with lengthening the examination. Overall, South African radiographers’ attitudes towards radiation protection, subjective norm, perceived behavioural control and radiation protection intention were high.

An audit of published South African diagnostic reference level data

Diagnostic reference levels (DRLs) are accepted as a dose optimisation tool for patients undergoing x-ray imaging and are required by South African (SA) legislation for 26 fluoroscopically guided procedures (FGPs). The aim of this paper is to collate all published SA data on DRLs in preparation for a project to establish national DRLs. Systematic searches were conducted of various applicable databases. All research that proposed DRLs for any imaging procedure in South Africa was included. Twenty-one works met inclusion criteria, the earliest from 2001. Two-thirds of all work reported on FGPs and five studies documented computed tomography DRLs. Three publications focussed exclusively on paediatric imaging DRLs. No studies on mammography or dental radiography were found. For clinical procedures with more than one proposed DRL, the range of proposed DRL varied by up to a factor of five. The highest proposed DRL is 373.1 Gy cm²for endovascular aneurysm/aortic repair procedures. Data were collected in six public hospitals and two private hospital groups. Thirty-six authors contributed to the manuscripts, but only six studies had an inter-disciplinary authorship. This is the first paper to provide a comprehensive review of SA DRL data and thereby advances international radiation protection initiatives. The data suggests there is room for more interdisciplinary work and that there must be rigorous standardization of reported parameters and data collection. This audit also highlights the need for standardized terminology, particularly for FGPs.

An audit of registered radiology equipment resources in Uganda

Introduction

the third Sustainable Development Goal (SDG) relates to Universal Health Coverage (UHC) and provision of quality essential health services. The Government of Uganda has operationalized this through the National Health Policy which stresses the importance of availability of functioning medical equipment in health facilities. There have been efforts by the Ministry of Health and Atomic Energy Council in Uganda to compile an inventory of imaging equipment in the country, however, this information has not been widely published. The purpose of this study was to conduct an audit of registered radiology equipment in Uganda and establish their functional status.

Methods

a cross-sectional descriptive study that involved a desktop review of the equipment registry at the Uganda Atomic Energy Council was conducted. Data was collected on a number of variables including type of equipment, location, functional status, modality and density per million people.

Results

the audit revealed 625 pieces of equipment spread over 354 health facilities. The majority (397) were plain X-ray machines followed by dental X-ray machines at 120. There were only 3 Radiotherapy machines. Most were recorded as being functional with only 0.1% of the equipment non-functional. Most of the equipment was in the central region which has the third highest population density. The majority of the equipment belonged to private health facilities.

Conclusion

Uganda lags behind the WHO recommended ratio of equipment versus the population (20 per million population). Most of the equipment is the plain X-ray machine with a few more advanced technologies in both public and private health facilities.

Yield of CT angiography in penetrating lower extremity trauma

PURPOSE

CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided.

METHODS

A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined.

RESULTS

A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001).

CONCLUSION

There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

The Cinderellas of the scanner: Magnetic resonance imaging 'pre-scan' and 'post-scan' times: Their determinants and impact on patient throughput

Background

Increasing demand for magnetic resonance imaging (MRI) has contributed to extended patient waiting times worldwide. This is particularly true in resource-limited environments, prompting this institutional workflow analysis.

Objective

To determine the ‘pre-’ and ‘post-scan’ times for normal-hour MRI studies conducted at a tertiary-level, public-sector South African hospital and to assess any association with demographic details, patient characteristics, anatomical site and scan parameters. A secondary objective was determination of the average daily MR ‘down’ time.

Methods

A prospective descriptive study stratifying MRI workflow into ‘pre-scan’, ‘scan’, ‘post-scan’ and ‘down’ times. During ‘pre-‘ and ‘post-scan’ times patients occupied the scanner whilst staff performed tasks indirectly contributing to image acquisition. During ‘down’ time no patient occupied the MRI room. ‘Pre-’ and ‘post-scan’ times were compared with demographic details, patient characteristics, anatomical site and study parameters, utilising correlation analysis or analysis of variance (ANOVA).

Results

A total of 223 patients (n = 223) underwent 286 investigations in the 23-day review period. Seventy per cent of routine working time was utilised in image acquisition. The ‘pre-’ and ‘post-scan’ times together accounted for 19% and ‘down’ time for 11% of working time. Prolonged ‘pre-’ and ‘post-scan’ times were independently associated with age less than 12 years, anaesthesia, sedation and immobility (p < 0.01 in all cases). The longest median combined ‘pre-’ and ‘post-scan’ time by anatomical site (cholangiopancreatography, 21:46 min) was more than six times the shortest (pituitary fossa, 3:11 min).

Conclusion

A critical analysis of magnetic resonance ‘pre-’ and ‘post-scan’ times can provide valuable insights into opportunities for enhanced service efficiency.

RSNA International Trends: A Global Perspective on the COVID-19 Pandemic and Radiology in Late 2020

The coronavirus disease 2019 pandemic has challenged and changed health care systems around the world. There has been a heterogeneity of disease burden, health care resources, and nonimaging testing availability, both geographically and over time. In parallel, there has been a continued increase in understanding how the disease affects patients, effectiveness of therapeutic options, and factors that modulate transmission risk. In this report, radiology experts in representative countries from around the world share insights gained from local experience. These insights provide a guidepost to help address management challenges as cases continue to rise in many parts of the world and suggest modifications in workflow that are likely to continue after this pandemic subsides.

Predictive value of a false-negative focused abdominal sonography for trauma (FAST) result in patients with confirmed traumatic abdominal injury

Objective

To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST.

Methods

This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST.

Results

FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038).

Conclusion

Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available.

An audit of licenced Zambian diagnostic imaging equipment and personnel

INTRODUCTION

Estimates indicate that two-thirds of the world's population lack adequate access to basic medical imaging services integral to universal health coverage (UHC). Furthermore, sparse country-level radiological resource statistics exist and there is scant appreciation of how such data reflect healthcare access. The World Health Organisation posits that one X-ray and ultrasound unit for every 50,000 people will meet 90% of global imaging demands. This study aimed to conduct a comprehensive review of licensed Zambian radiological equipment and human resources.

METHODS

An audit of licensed imaging resources, using the national updated Radiation Protection Authority and Health Professions Council of Zambia databases. Resources were quantified as units or personnel per million people, stratified by imaging modality, profession, province and healthcare sector, then compared with published Southern African data.

RESULTS

Over half of all equipment (153/283 units, 54%) and almost two thirds of all radiation workers (556/913, 61%) are in two of ten provinces, serving one third of the population (5.49/16.4, 33.5%). Three-quarters of the national equipment inventory (212/283 units, 75%) and nearly ninety percent of registered radiation workers (800/913, 88%) are in the public sector, serving 96% of the population. Southern African country-level public-sector imaging resources principally reflect national per capita healthcare spending.

CONCLUSION

To achieve equitable imaging access pivotal for UHC, Zambia will need a more homogeneous distribution of specialised radiological resources tailored to remedy disparities between healthcare sectors and provincial regions. Analyses of licenced radiology resources at country level can serve as a benchmark for medium-term radiological planning.

An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity

Introduction

Approximately two-thirds of the world's population has no access to diagnostic imaging. Basic radiological services should be integral to universal health coverage. The World Health Organization postulates that one basic X-ray and ultrasound unit for every 50000 people will meet 90% of global imaging needs. However, there are limited country-level data on radiological resources, and little appreciation of how such data reflect access and equity within a healthcare system. The aim of this study was a detailed analysis of licensed Zimbabwean radiological equipment resources.

Methods

The equipment database of the Radiation Protection Authority of Zimbabwe was interrogated. Resources were quantified as units/million people and compared by imaging modality, geographical region and healthcare sector. Zimbabwean resources were compared with published South African and Tanzanian data.

Results

Public-sector access to X-ray units (11/10⁶ people) is approximately half the WHO recommendation (20/10⁶ people), and there exists a 5-fold disparity between the least- and best-resourced regions. Private-sector exceeds public-sector access by 16-fold. More than half Zimbabwe's radiology equipment (215/380 units, 57%) is in two cities, serving one-fifth of the population. Almost two-thirds of all units (243/380, 64%) are in the private sector, routinely accessible by approximately 10% of the population. Southern African country-level public-sector imaging resources broadly reflect national per capita healthcare expenditure.

Conclusion

There exists an overall shortfall in basic radiological equipment resources in Zimbabwe, and inequitable distribution of existing resources. The national radiology equipment register can reflect access and equity in a healthcare system, while providing medium-term radiological planning data.

Infantile intrathoracic large airway obstruction in a setting with a high prevalence of tuberculosis/HIV

Background There has been no detailed analysis of the cause of intrathoracic large airway obstruction in infants in a resource-limited environment with a high prevalence of pulmonary tuberculosis (PTB) and human immunodeficiency virus (HIV). Aim To define the aetiology and severity of intrathoracic large airway obstruction in infants in a tertiary South African hospital with a high prevalence of PTB and HIV. Methods A retrospective study of infants was conducted with computerised tomography (CT) evidence of intrathoracic large airway obstruction from 1 January 2011 to 31 May 2014. CT scans were evaluated for the cause, site and severity of airway narrowing, with severity stratified as 'mild' (<50%), 'moderate' (51-75%) or 'severe' (>75%). Results Forty-four patients (28 males, 64%; median age 145 days, range 5-331), and 79 sites of attenuation were included. Vascular (22/44, 50%) and nodal (18/44, 41%) compressions accounted for over 90% of cases. Thirty-five patients (79.5%) had at least one site of moderate/severe attenuation, and 26 (59%) had multiple such sites. Adenopathy was the commonest cause of moderate/severe compression (18/35, 51%). All cases of nodal compression were of tuberculous origin. HIV-serology was recorded in 32 patients (73%), one of whom, with vascular compression, was HIV-infected. Half of the patients (11/22, 50%) with vascular compression had congenital abnormalities, most commonly cardiac anomalies (7/22, 32%). There were no synchronous vascular and nodal compressions. Conclusion Infantile intrathoracic large airway obstruction where there is a high prevalence of PTB and HIV is characterised by its extrinsic aetiology, severity and multicentricity, with more than half of all moderate/severe obstructions being caused by tuberculous adenopathy.

Defining the diagnostic divide: an analysis of registered radiological equipment resources in a low-income African country

INTRODUCTION

Diagnostic radiology is recognised as a key component of modern healthcare. However there is marked inequality in global access to imaging. Rural populations of low- and middle-income countries (LMICs) have the greatest need. Carefully coordinated healthcare planning is required to meet the ever increasing global demand for imaging and to ensure equitable access to services. However, meaningful planning requires robust data. Currently, there are no comprehensive published data on radiological equipment resources in low-income countries. The aim of this study was to conduct the first detailed analysis of registered diagnostic radiology equipment resources in a low-income African country and compare findings with recently published South African data.

METHODS

The study was conducted in Tanzania in September 2014, in collaboration with the Tanzanian Atomic Energy Commission (TAEC), which maintains a comprehensive database of the country's registered diagnostic imaging equipment. All TAEC equipment data were quantified as units per million people by imaging modality, geographical zone and healthcare sector.

RESULTS

There are 5.7 general radiography units per million people in the public sector with a relatively homogeneous geographical distribution. When compared with the South African public sector, Tanzanian resources are 3-, 21- and 6-times lower in general radiography, computed tomography and magnetic resonance imaging, respectively.

CONCLUSION

The homogeneous Tanzanian distribution of basic public-sector radiological services reflects central government's commitment to equitable distribution of essential resources. However, the 5.7 general radiography units per million people is lower than the 20 units per million people recommended by the World Health Organization.