The Impact of COVID-19 on the Utilization of Public Sector Radiological Services in the Western Cape Province of South Africa

Background Coronavirus (COVID-19) was officially declared a pandemic in March 2020 and has had a major impact on global healthcare services, including radiology. However, little is known about the full impact of COVID-19 on the utilization of diagnostic imaging in Africa's public healthcare sector. Objectives The objective of this study was to compare public sector diagnostic imaging utilization by modality for the whole Western Cape Province (WCP) of South Africa (SA), as well as its metropolitan and rural areas, in 2019 and 2020 in terms of the absolute number of investigations and investigations per 1000 people. Method We performed a retrospective analysis of Western Cape Government Department of Health and Wellness and Stats SA District Council 2021 Mid-Year Population Estimates data. All diagnostic imaging investigations performed in 2019 and 2020 were collated and stratified by imaging modality, geographic region (metropolitan/rural), and calendar year. Data are presented as the total number of investigations and investigations per 1000 people. We calculated mammography utilization for women aged 40-70 years and compared data for 2019 and 2020. Results Between 2019 and 2020, the provincial population increased by 1.9%, while total imaging investigations and investigations per 1000 people decreased by 19% (1,384,941 vs. 1,123,508, -261,433) and 20% (262/103 vs. 208/103), respectively. Total numerical decline was highest in plain radiographs (1,005,545 vs. 800,641, -204,904), accounting for more than three-quarters (78%) of the total reduction. Percentage decline was most pronounced for mammography, as utilization was almost halved (15.7/103 vs. 8.9/103, -43%), whereas computed tomography was the least impacted (17.9/103 vs. 16.7/103, -12%) with the remaining modalities decreasing between approximately one-quarter and one-fifth (magnetic resonance imaging = 26%, fluoroscopy = 25%, general radiographs = 23%, ultrasound = 16%, chest radiographs = 18%). Proportional metropolitan (-18.7%) and rural decreases (-19.3%) were similar. Conclusion COVID-19 had a substantial impact on WCP imaging services, decreasing overall radiological investigations by almost one-fifth. The greatest impact was on elective investigations, particularly mammography. Although the proportional impact was similar for the metropolitan and rural areas, COVID-19 nonetheless exacerbated existing discrepancies in imaging utilization between the geographical regions. The medium- and long-term clinical impacts of decreased imaging are still to be defined.

The use of lung ultrasound in COVID-19

This review article addresses the role of lung ultrasound in patients with coronavirus disease 2019 (COVID-19) for diagnosis and disease management. As a simple imaging procedure, lung ultrasound contributes to the early identification of patients with clinical conditions suggestive of COVID-19, supports decisions about hospital admission and informs therapeutic strategy. It can be performed in various clinical settings (primary care facilities, emergency departments, hospital wards, intensive care units), but also in outpatient settings using portable devices. The article describes typical lung ultrasound findings for COVID-19 pneumonia (interstitial pattern, pleural abnormalities and consolidations), as one component of COVID-19 diagnostic workup that otherwise includes clinical and laboratory evaluation. Advantages and limitations of lung ultrasound use in COVID-19 are described, along with equipment requirements and training needs. To infer on the use of lung ultrasound in different regions, a literature search was performed using key words "COVID-19", "lung ultrasound" and "imaging". Lung ultrasound is a noninvasive, rapid and reproducible procedure; can be performed at the point of care; requires simple sterilisation; and involves non-ionising radiation, allowing repeated exams on the same patient, with special benefit in children and pregnant women. However, physical proximity between the patient and the ultrasound operator is a limitation in the current pandemic context, emphasising the need to implement specific infection prevention and control measures. Availability of qualified staff adequately trained to perform lung ultrasound remains a major barrier to lung ultrasound utilisation. Training, advocacy and awareness rising can help build up capacities of local providers to facilitate lung ultrasound use for COVID-19 management, in particular in low- and middle-income countries.

Diagnostic yield and accuracy of paediatric image-guided fine needle aspiration biopsy of deep organ tumours

Background

Paediatric tumour cytological diagnosis by image-guided fine needle aspiration biopsy (FNAB) with rapid on-site evaluation (ROSE) has not gained wide acceptance despite increasing publications advocating the procedure.

Objective

The primary aim was an audit of the diagnostic yield and accuracy of paediatric image-guided FNAB with ROSE at a single institution. Evaluation of safety was a secondary aim.

Method

Details of consecutive cases of paediatric image-guided FNAB with ROSE for suspected non-benign deep-seated lesions performed from 01 January 2014 to 30 April 2020 were retrieved from the institutional radiology and laboratory databases. Diagnostic yield and accuracy were evaluated using clinico-pathological-radiological correlation and/or subsequent histological specimen diagnosis correlation. Complications and the frequency of key radiological features potentially affecting yield and accuracy were described.

Results

Of 65 cases retrieved, cytology showed malignancy in 52, benign features in five and one indeterminate diagnosis; seven samples were insufficient for cytological assessment. Of the 65 cases, 58 had subsequent formal histological diagnosis. The overall diagnostic yield was 98.5%, with 94.5% sensitivity, 100.0% specificity, 100.0% positive predictive value, 75.0% negative predictive value and 95.3% diagnostic accuracy. All cases (n = 26) demonstrating restricted diffusion on MRI yielded adequate samples and cyto-histopathological correlation.

Conclusion

Paediatric image-guided FNAB with ROSE has a relatively high diagnostic yield, sensitivity, specificity, positive predictive value and accuracy in the diagnosis of deep-seated tumours. The relatively low negative predictive value may reflect insufficient samples obtained from cystic and/or benign lesions. Sampling from areas of restricted MRI diffusion may enhance diagnostic yield.

Temporal Trends in the South African Diagnostic Radiology Workforce (2002-2019)

Background

To facilitate imaging resource planning and address key health targets of the United Nations (UN) 2030 Sustainable Development Goals, accurate data are required on imaging personnel at the country level. Such data are currently limited.

Objectives

This study aims to analyze trends in the number, geographical distribution, and demographics of South African (SA) diagnostic imaging personnel between 2002 and 2019.

Method

A retrospective analysis of the Health Professions Council of South Africa (HPCSA) database of imaging personnel from 2002 to 2019 was done. The total number of personnel and personnel per million people were calculated for the country and for each professional group (radiologist, diagnostic radiographer, and sonographer) by calendar year, province, and demographic profile. Population data were provided by Statistics SA.

Results

The total imaging personnel, number per million people, and national population increased by 283% (3,095 versus 8,753), 119% (68 versus 149/10⁶), and 29% (45.45 versus 58.77/10⁶), respectively.

Diagnostic radiographers constituted more than 80% of the workforce throughout the review period, increasing by 185% (2,540 versus 7,242). Sonographers, the smallest cohort, recorded the highest (49 versus 503; 906%) and radiologists (506 versus 1,007; 99%) the lowest proportional growth.

Although radiologists showed persistent male predominance, the male proportion decreased from 82% to 69%, while that of females increased from 18% to 31%. The average annual percentage increase in female radiologists (14%) was more than three times that of males (4%).

Diagnostic radiographers showed female predominance, but the proportion decreased from 90% to 83%, while that of males increased from 10% to 17%. Sonographers showed overwhelming female predominance (94% versus 92%). The average annual percentage increase in male diagnostic radiographers (21%) was more than double that of females (9%).

In 2002, 48% (n = 1,475) of imaging personnel identified as White, and 15% (n = 467) identified as Black African. By 2019, those identifying as White and Black African were 36% (n = 3,122) and 35% (n = 3,045), respectively.

The Western Cape Province (WCP) maintained the highest overall number of imaging personnel per million people (165 versus 233/10⁶) and Limpopo the lowest (12 versus 54/10⁶). However, Limpopo recorded the highest proportional growth in imaging personnel/10⁶ people (368%) and the WCP the lowest (41%). The differential between the best- and least-resourced provinces thus decreased from 14:1 in 2002 to 4:1 in 2019.

Conclusion

In the review period, the SA imaging workforce has shown substantial expansion and transformation and has assumed a more equitable distribution.

Thoracic ultrasound for TB diagnosis in adults and children

Thoracic ultrasound is an appealing alternative to chest radiography for the diagnosis of TB. Based on research experience conducting thoracic ultrasound for adults and children in South Africa, three key considerations for potential scale-up were identified. First, thoracic ultrasound requires a comprehensive training programme for novice users; artificial intelligence may be used to simplify training and interpretation. Second, a robust ultrasound device is needed with good subpleural resolution and a probe suitable for children. Third, comprehensive scanning of the lungs is time-intensive, and shorter scanning protocols may be more feasible in clinical practice.

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 FC Rad Diag(SA): Stretched, but still in step – Report on a Royal College observership

A delegation of the College of Radiologists of the overarching Colleges of Medicine of South Africa observed the spring sitting of the Part 2B Examination of the Fellowship of the Royal College of Radiologists (FRCR) in London, in April 2016. Although the principal focus of the Observership was the Part 2B examination, the delegates also assessed broader aspects of the FRCR. This report presents an overview of current FRCR practices, including the findings of an independent review of the FRCR, and reflects on the implications for the South African Fellowship examination. The report is based on discussions with key Royal College role players, direct observation of the Part 2B examination and web-based documentation. It allows appreciation of the continued close alignment of the FC Rad Diag(SA) (Fellowship of the College of Radiologists of the Colleges of Medicine of South Africa) with the FRCR and highlights expected trends in the FC Rad Diag(SA). It also documents the increasing human resources required for successful conduct of examinations. It is hoped that the report will be of interest and relevance to the broad South African radiological community and to those contemplating specialist training in the discipline. It is trusted that it will encourage wider involvement of radiological and medical physics colleagues in the various FC Rad Diag(SA) examination processes.

Diagnostic reference levels for paediatric computed tomography

Objectives: To establish local diagnostic reference levels (LDRLs) for emergency paediatric head computed tomography (CT) scans performed at a South African (SA) tertiary-level hospital and to compare these with published data.Materials and methods: A retrospective analysis was conducted of volume-based CT dose index (CTDIvol) and dose length product (DLP) data from uncontrasted paediatric head CT scans performed in the Trauma and Emergency Unit of a tertiary-level SA hospital from January to June 2013. A random sample of 30 patients in each of 3 age groups (0–2, >2–5 and >5–10 years) was used. LDRL values were compared with several national DRLs from Europe and Australia. Results: Mean CTDIvol and DLP values were: 30 mGy and 488 mGy.cm for the 0–2 years age group; 31 mGy and 508 mGy.cm for the >2–5 years group, and 32 mGy and 563 mGy.cm for the >5–10 years group, respectively. The mean DLP for 0–2 year-olds was the only parameter outside the range of corresponding published reference data. Stratification into narrower age groupings showed an increase in DLP values with age. Conclusion: An institutional review of the head CT scanning technique for emergency studies performed on children less than 2 years of age is recommended. The current study highlights the role of LDRLs in establishing institutional dosimetry baselines, in refining local imaging practice, and in enhancing patient safety. Standard age stratification for DRL and LDRL reporting is recommended.

Towards task shifting? A comparison of the accuracy of acute trauma-radiograph reporting by medical officers and senior radiographers in an African hospital

INTRODUCTION

Due to the universal shortage of radiologists, medical officers are largely responsible for acute trauma radiograph reporting in public sector healthcare facilities in well-resourced countries. In poorly-resourced countries, a shortage of medical officers results in most acute trauma radiographs being unreported. In the European Union (EU), experienced radiographers with no specific training have been shown to be more accurate than medical officers in trauma radiograph reporting, while EU radiographers who receive additional training can reach accuracies comparable to radiologists. In some EU countries, the role of the radiographer has been extended to include trauma reporting. However, there has been no study of the accuracy of trauma radiograph reporting by radiographers in Africa, where task-shifting could yield potentially greater benefits, due to shortages of both radiologists and medical officers. The aim of this study was therefore to compare the accuracy of acute trauma-radiograph reporting by medical officers and senior radiographers in an African setting.

METHODS

A prospective study was conducted at a South African hospital from November 2013-April 2014. Medical officers and senior radiographers reported the same set of appendicular skeleton trauma radiographs. Reporting accuracy, sensitivity and specificity were calculated using a consultant radiologist's report as the reference standard. Differences were evaluated using the Mann-Whitney U test, with p < 0.05 significant.

RESULTS

Senior radiographers achieved significantly higher reporting accuracy and sensitivity than medical officers (81.5% vs 67.8%, p = 0.002).

CONCLUSION

Senior radiographers represent a potentially important resource for acute trauma-radiograph reporting in the public healthcare sector in Africa.

The accuracy of radiology speech recognition reports in a multilingual South African teaching hospital

Background

Speech recognition (SR) technology, the process whereby spoken words are converted to digital text, has been used in radiology reporting since 1981. It was initially anticipated that SR would dominate radiology reporting, with claims of up to 99% accuracy, reduced turnaround times and significant cost savings. However, expectations have not yet been realised. The limited data available suggest SR reports have significantly higher levels of inaccuracy than traditional dictation transcription (DT) reports, as well as incurring greater aggregate costs.

There has been little work on the clinical significance of such errors, however, and little is known of the impact of reporter seniority on the generation of errors, or the influence of system familiarity on reducing error rates.

Furthermore, there have been conflicting findings on the accuracy of SR amongst users with English as first- and second-language respectively.

Methods

The aim of the study was to compare the accuracy of SR and DT reports in a resource-limited setting. The first 300 SR and the first 300 DT reports generated during March 2010 were retrieved from the hospital’s PACS, and reviewed by a single observer. Text errors were identified, and then classified as either clinically significant or insignificant based on their potential impact on patient management. In addition, a follow-up analysis was conducted exactly 4 years later.

Results

Of the original 300 SR reports analysed, 25.6% contained errors, with 9.6% being clinically significant. Only 9.3% of the DT reports contained errors, 2.3% having potential clinical impact. Both the overall difference in SR and DT error rates, and the difference in ‘clinically significant’ error rates (9.6% vs. 2.3%) were statistically significant. In the follow-up study, the overall SR error rate was strikingly similar at 24.3%, 6% being clinically significant.

Radiologists with second-language English were more likely to generate reports containing errors, but level of seniority had no bearing.

Conclusion

SR technology consistently increased inaccuracies in Tygerberg Hospital (TBH) radiology reports, thereby potentially compromising patient care. Awareness of increased error rates in SR reports, particularly amongst those transcribing in a second-language, is important for effective implementation of SR in a multilingual healthcare environment.

An audit of elective outpatient magnetic resonance imaging in a tertiary South African public-sector hospital

Background: Increasing demand for magnetic resonance imaging (MRI) has resulted in longer waiting times for elective MRI, particularly in resource-limited healthcare environments.However, inappropriate imaging requests may also contribute to prolonged MRI waiting times. At the time of the present study, the waiting time for elective MRI studies at Tygerberg Hospital (TBH), a tertiary-level public-sector healthcare facility in Cape Town (South Africa),was 24 weeks.Objectives: To document the nature and clinical appropriateness of scheduled TBH outpatient MRI examinations.Method: A retrospective analysis of the referral forms of all elective outpatient MRIexaminations scheduled at TBH from 01 June to 30 November 2011 was conducted. Patient age, gender, clinical details, provisional diagnosis, examination requested and referring clinician were recorded on a customised data sheet. Two radiologists independently evaluated the appropriateness of each request by comparing the clinical details and the provisional diagnosis provided with the 2012 American College of Radiology (ACR) guidelines for the appropriate use of MRI.Results: Four hundred and sixty-six patients (median age 42 years; interquartile range 19–55) who had 561 examinations were scheduled in the review period; 70 (15%) were children less than 6 years old. Neurosurgery (n = 164; 35%), orthopaedic (n = 144; 31%),neurology (n = 53; 11%) and paediatric (n = 27; 6%) outpatients accounted for the majority(81%) of referrals; 464 (99.6%) were from specialist clinics. MRIs of the spine (n = 314; 56%),brain (n = 152; 27%) and musculoskeletal system (n = 70, 13%) accounted for more than 95%of the investigations. In 455 cases (98%), the referral was congruent with published ACR guidelines for appropriate MRI utilisation.Conclusion: Scheduled outpatient MRI examinations at TBH reflect optimal clinical use of a limited resource. MRI utilisation is largely confined to traditional neuro-imaging. Any initiative to decrease the elective MRI waiting time should focus on service expansion.

The dissertation generaltion

N/A

Digital radiographic measurement of the atlantodental interval in children

The atlantodental interval (ADI) is assessed after trauma to the head and neck region to determine whether the transverse ligament of the atlas is intact. Atlantodental interval measurement from conventional screen-film radiographs is characterized by the need for magnification correction and by low reliability. Assessment of normal ADI values using digital radiography with computer-assisted measurement has not been reported. We compared with published values the digital radiographic measurements of ADI in children, examined the reliability of measurements, and examined the interaction between age, sex and ADI. Computer-assisted digital measurements of ADI in 101 children, aged 1 to 12 years, were obtained from lateral supine head-neutral radiographs. We found intraobserver reliability of 0.72 and 0.85, interobserver reliability of 0.50, a maximum ADI value of 3.5 mm, no effect of sex and age, and weak evidence for an interaction between sex and age. Computer-assisted digital ADI measurement provides higher intraobserver reliability than what has previously been reported, and interobserver reliability and a maximum ADI value similar to that found in the literature.

Multiple injuries diagnosed using full-body digital x-ray

Missed injuries in patients with multiple trauma are primarily attributable to inadequate radiography. A case is presented that demonstrates the value of a full-body digital radiography system in diagnosing pathology in pediatric multiple trauma patients. Full-body imaging allowed the identification of a ruptured diaphragm, a pelvic fracture, and a femoral fracture on a single radiographic projection in the resuscitation room, facilitating immediate intervention.

Clinical course of hospitalised children infected with human metapneumovirus and respiratory syncytial virus

AIM

To describe the clinical presentation and outcomes of hospitalised patients infected with human metapneumovirus (hMPV) and human respiratory syncytial virus (hRSV) in a tertiary hospital in Cape Town, South Africa.

METHODS

hMPV was identified in 17 respiratory specimens submitted for viral studies during the period 2001-2003. These patients' medical folders were retrospectively reviewed for clinical, radiological and laboratory data, together with a convenience sample of 20 hRSV-infected patients.

RESULTS

hMPV-infected patients were older than those infected with hRSV (P = 0.04) and required a longer hospital stay (P = 0.02). Presenting clinical signs and symptoms were similar between groups. Fourteen (87.5%) hMPV- and 16 (80%) hRSV-infected patients presented with co-morbid and/or immunosuppressive conditions (P > or = 0.5). The most common abnormalities on chest radiographs in both groups were bronchial wall thickening, focal consolidation and atelectasis. Six (37.5%) hMPV- and 11 (55%) hRSV-infected patients required admission to the paediatric intensive care unit (P > 0.1) with five (31.3%) hMPV- and eight (40%) hRSV-infected patients requiring intubation and ventilation (P > 0.5). Three (18.7%) hMPV-patients and three (15%) hRSV-infected patients died during this admission (P > 0.5). All hMPV-infected patients who died had significant co-morbid conditions.

CONCLUSIONS

These data confirm that hMPV is a significant respiratory pathogen in this setting, with similar presentation and outcome to hRSV infection. This is the largest report of hMPV infection causing significant morbidity, prolonged hospital stay and death, associated with underlying risk factors.

Primary neuroblastoma: a rare cause of a retropharyngeal mass in a neonate

Neuroblastoma is the most common extra-cranial solid malignancy in children and the most common tumour occurring during infancy. This tumour arises from undifferentiated precursor cells of the sympathetic nervous system. The abdomen (65 per cent) is the most common site for these tumours, followed by the throat (15 per cent), pelvis (5 per cent) and cervical region (5 per cent).

We report a case of primary retropharyngeal neuroblastoma in a three-week-old baby boy presenting with upper airway obstruction

Plants rendered herbicide-susceptible by cauliflower mosaic virus-elicited suppression of a 35S promoter-regulated transgene

Crop plants genetically modified for herbicide tolerance were some of the first to be released into the environment. Frequently, the cauliflower mosaic virus (CaMV) 35S promoter is used to drive expression of the herbicide tolerance transgene. We analyzed the response to CaMV infection of a transgenic oilseed rape line containing the bialaphos tolerance gene (BAR) from Streptomyces hygroscopicus, regulated by the 35S promoter. Oilseed rape is susceptible to CaMV, but plants recover from infection. CaMV infection altered the expression of the herbicide tolerance gene such that plants became susceptible to the herbicide. The effect on transgene expression differed in infections with viral pathogenic variants typical of those found in natural situations worldwide. Susceptibility to the herbicide was most likely a result of transcriptional gene silencing of the transgene. Our results show that transgene phenotypes can be modified by pathogen invasion.