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MSF

Médecins Sans Frontières/Doctors without Borders


Tele-reading

 The WFPI is collaborating with Médecins sans Frontières/Doctors without Borders (MSF) to provide pediatric imaging telereporters to support MSF’s global telemedicine network, using platforms and technology already set up in project sites. See this MSF video explaining how the system works, "bringing some of the best medicine to some of the worst off patients in the world". 

 

A rising number of WFPI volunteers are enlisted on the Collegium Telemedicus platform to tele-read for MSF, including Drs. Savvas Andronikou, Michelle Fink, Karen Checuti, Keiran McHugh and Anne Geoffray. Our  TB "hotline" group is about to join the team as MSF tele-reading expands. The flow of pediatric cases originating from all over the world has now reached the hundreds with subsequent exchange occurring on some. The platform works well, though the quality of images referred is highly variable.


See WFPI's mini-symposium, "Outreach in the Developing World" and our list of telemedicine literature here for articles on MSF's tele-radiological history and quality assurance/lessons learnt. 

Discussions are underway with MSF's diagnostic imaging network for expanding WFPI's support. Our strong tuberculosis focus dovetails with MSF's TB drive: see here for MSF's TB overview, associated literature and films 

 

Another priority topic shared by MSF and WFPI: point of care ultrasound in lower resource settings. With field use on the rise in MSF, pediatricultrasound experts have joined under the auspices of WFPI to co-author MSF's new pediatric ultrasound manual (internal use only for now)


© Raghu Venugopal/MSF


Other MSF work

MSF sends doctors to South Africa for HIV training where pediatric imaging sessions have been delivered WFPI's South African pediatric imaging team.

One of WFPI's active volunteers, Savvas Andronikou (former WFPI outreach leader), assists in the production of MSF diagnostic guidelines. He recently co-authored an article on a quality assessment of X-rays interpreted via tele-radiology for MSF, accepted for publication in the Journal of Telemedicine and Telecare. The growing body of MSF-led publications on tele-radiology is available here. Savvas has also led the contributions to MSF's lower resource ultrasound ("Point of Care) manual. Other authors included Drs. Dorothy Bulas, Cicero Silva, Tracy Kilburn and Keiran McHugh. 

 

Two "Seven Minute Snippets" (short videos) on the interpretation of pediatric tuberculosis CXR films were co-produced with MSF in South Africa; now incorporated into WFPI's online library here. 

LAOS, CAMBODIA AND JAMAICA


Laos Friends Hospital for Children

 

Laos Friends Hospital for Children opened its doors in Feburary 2015. Set up and supported by Friends Without a Border (as is Angkor Hosital for Children in Cambodia, above), LFHC is the first full-service pediatric hospital in northern Laos, offering inpatient & outpatient departments, 24 beds, emergency room, intensive care unit, operation theater, laboratory, pharmacy, radiology, lecture rooms & library to teach pediatric medicine to the future leaders of the hospital, kitchen & laundry for families visiting the hospital, and a vegetable garden to teach families how to prepare nutritious meals. 

See Friends Without a Border website (here) for more background information on the initiation of this new and much welcomed hospital. 


As of late 2015: the hospital is developing fast:

+ Currently offers outpatient and inpatient (20 beds) services with approximately 5 Laotian MD’s seeing approximately 70 patients a day with the performance of approximately 2-10 radiological exams (combined radiographs and ultrasounds) per day
+ November 2015: ER opened
+ January 2016: scheduled opening of the ICU and operating room theater

The hospital continues to expand radiological services + site visits for sonographers + continuing RAD-AID support of PACS

 

RAD-AID's pediatric coordinator for Asia, Dr Michael Reiter, visited LFHC in May 2015 to assess future collaboration and support. Following the visit, Dr Reiter and LFHC's director, Dr. Nijssen-Jordan, contacted WFPI for tele-second opinions for LFHC's embyronic imaging department (the hospital does not have a radiologist hired yet to interpret the images for a newly installed US and portable radiography unit).  

Tele-expertise progress report, March 2016: over 500 cases referred to WFPI by LFCH via the tele-platform. Most cases have been chest radiographs, also radiographs of skull, mandible, spine, leg, and abdomen, as well as one head CT. They raised diverse clinical questions, including queries on infection, heart failure, beriberi, storage disease, tuberculosis, sellar tumor, dental abscess, thalassemia and acute abdomen

Training visit to LFCH, March 2016 - see report below

WFPI teaching at LFCH in March 2016see visit report HERE 

 More background information on this project and the pediatric imaging set up can be found here

Laos Friends Children's Hospital is looking for a volunteer Xray and US technician visit: see here.

 

    

Angkor Hospital for Children, Siem Reap, Cambodia


Angkor Hospital for Children (AHC) is a 103 bed charity pediatric hospital serving children affected by poverty and disease. Founded in 1999, the hospital has grown to include a 12 bed intensive care unit, a surgery program including open heart surgery cases assisted by visiting teams, the beginnings of a cancer care program, a neonatal ward and a newly renovated and expanded outpatient department. More information can be found at www.angkorhospital.org.

AHC’s two radiology modalities are X-ray and ultrasound (no CT scanner or MRI Machine. CT scans are occasionally obtained at other facilities in Siem Reap on an as needed basis.) The good quality images are done with a very simple mobile machine. A phosphor plate system is in place, thus X-Rays and descriptions can be reached from the ward. ACH uses SONIX SP (ultrasonix) ultrasound machine with three probes:  C7-3/50 , L14-5/38 and PA4-2/20. Since its repair in early March 2014, the machine has ceased to function with Pulsed and Power Doppler. There are 15-20 ultrasound examinations/day, mainly severe  soft tissue masses and eye injuries. There is no small convex probe. Generally speaking there are no normal finding, just severe pathologies. AGH has one radiologist and plans to add an additional physician to train as a pediatric radiologist.To date WFPI has given opinions on aproxmiately 120cases, largely on plain radiographs, with a few ultrasound studies, contrast exams and CTs. Opinions were returned within 24 hours (often sooner). 

Site coordinator: Dr. Seng Hap. WFPI coordinators and tele-readers: Drs. Veronica Donoghue and Eva Kis. Project identified by Dr. Catherine Owens/Royal College of Radiologists, UK

© Cambodia images: George Taylor 

Other imaging interventions at Angkor Hospital for Children 

WFPI is far from the only organization to offer assistance to this facility. AHC pediatric staff members are trained by ultrasound faculty at UMass Memorial Medical Center through onsite lectures and hands on training. UMass physicians travel to Siem Reap about 3-4 times per year for onsite education. Pediatric radiologist Dr. Joe Makris has been among them. See here for more. 



Mozambique

Maputo Central Hospital, Mozambique


As a follow up to WFPI's ties and education work with Maputo Central Hospital (see here), the hospital lnow seeks second opinions on difficult pediatric imaging cases from WFPI via the Collegium Telemedicus tele-platform. Referred from onsite by Drs. Josina Chalufo and Williiam Buck, WFPI tele-volunteers include Drs. Ricardo Faingold , Cicero Silva, Ines Boechat, Denise Castro and Henrique Lederman. Dr. Carolina Guimaraes is on standby for neuro. Most cases are chest CXRs, the hospitals CT machine was broken down for long months over 2015. Update Nov 2015: 12 referrals; mostly CT chest: infection, congenital.

Right: Prof. Ines Boechat (WFPI President) teaching in Maputo, Mozambique, March 2014

Above: Dr. Josina Chalufo of Central Hospital Maputo with Prof. Ines Boechat during a pediatric imaging rotation at UCLA, July 2014 

  

for the WFPI/UCLA Center for Global Health teaching trip 2014 and learn more about this facility

  






 

 

 

 

Bustamante Children's Hospital, Kingston, Jamaica

Bustamante Children's Hospital offers 283 beds, including 5 in the ICU. The hospital is usually overcrowded and has long waiting times for diagnostic and medical interventions as well as outpatient consultations. The Accident and Emergency department operates on a 24/7 basis and sees approximately 77,000 patients per year.

The imaging department serves an overwhelming number of about 4000 patients for examinations per month from all over the Island (the vast majority is outpatient). CT scans and MRIs are done on about 80 and 20 pediatric patients respectively per month. Update August 2015: 2 cases referred; MR brain and spine: tumor, multiple sclerosis. MRI machine broken down for many weeks. 

In July 2015, Dr. Pamela D. Ketwaroo (Boston CHildren's, USA) visited Bustamante Hospital on behalf of WFPI. Here's what she reports:

On a fiery July afternoon in Kingston, Jamaica, my family and I were welcomed into Bustamante Children’s Hospital.  Dr. Michelle-Ann Richards-Dawson, the senior medical officer, and Dr. Marcia Lawrence, the sole pediatric radiologist at Bustamante, met me with warmth and generosity that is so typical of Jamaica.  I learned during my tour of the expansive and airy facilities that in the best of times, clinicians here rely primarily on radiographs, one ultrasound unit (which is shared with cardiology), and fluoroscopy.  CT and MRI are available at Kingston Public Hospital, where both patients and Dr. Lawrence are transported to and fro for imaging and interpretation, respectively.  They have made the best of a difficult situation, but with the more recent loss of their fluoroscopy unit as well, it made me wonder: what are some alternative ways to diagnose (and sometimes treat) pediatric GI emergencies without the benefit of fluoroscopy?  In resource-limited settings, the lack of fluoroscopy is not so uncommon, and pediatric radiologists can be in the forefront of helping these patients.  If we think creatively and draw upon collective experience, perhaps overcoming challenges like these will not be so overwhelming.

Image: L -> R, Dr. Marcia Lawrence, Dr. Richards-Dawson and Dr. Pamela Ketwaroo 

Site coordinator: Dr. Marcia Lawrence. WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez and PAHO/WHO.

Click here for more information on Bustamante Hospital 


The needs are vast - yet uptake slow.... What's the deal with telereading?

While experiencing growing success in the NGO arena, telereading has not always proved the hoped-for panacea in terms of providing affordable and ongoing imaging support to state-run facilities located medically underserved areas. 

Apart from the key challenge of lack of control over image quality/safety at the radiology-site, which limits the usefulness of remote interpretation, there is also a frequently observed reluctance to implement teleradiology referrer-side. RAD-AID, in its 2013 White Paper, suggests that this might be explained by the concerns in many countries that outside interpretation (i) lacks accountability, (ii) drains local health care economy of necessary expertise, and (iii) distorts communication across health care providers when radiology personnel are physically absent.

WFPI has observed a major obstacle when working in partnership with Minstry of Health (MoH) healthcare centers: access to computers with internet. Many MoH staff cannot secure this access easily, and when they do, their internet bandwidth speed can be slow. Already challenged by financial issues and towering patient loads, there is simply little time to spare for the hours required uploading.


It bears noting that when tele-reading passes through an NGO (MSF/DWB, Imaging the World), with project-dedicated, remunerated staff onsite, telereading flow can be considerable higher. Is this "middle man" a necessity or can we find success when working directly with MOH/other facility staff?

To this end, WFPI is planning research on secured mobile applications, including one offered by our tele-reading platform Collegium Telemedicus. Hopefully this will facilitate many sites that need imaging support but do not have the facility-based infrastructure required to receive tele-opinions. Smart phones, however, are ubiquitous. 


Dr. Isabel Jimeno, a pediatrican, kindly allowed us to enlist her services to help Collegium Telemedicus develop its mobile interface during her recent 6 months' work in Equatorial Guinea.

Smart phones: who doesn't have one?

The situation has been pithily summed up as follows: "The great leveller: New information technologies are reaching the world’s poor much faster than food and toilets. A recent UN report suggested six billion people have access to mobile phones, while only 4.5 billion have access to working toilets. There are around one billion mobile phones in both China and India. Africa is home to twice as many mobile phones as the United States and is the most advanced continent when it comes to “mobile money”. Developing countries accounted for 80 percent of new mobile subscriptions in 2011, with the number of Internet users doubling over a four year period. Technology offers great potential to enhance education opportunities, dramatically improve health outcomes, promote free speech and democracy, and offer greater access to global markets. The Internet is the key driver of global connectivity and opportunity, but different bandwidth speeds, limited access, and contrasting levels of openness can mean that the Internet exacerbates rather than offsets inequality." ("Now for the Long Term", a report written by the Oxford Martin Commission for Future Generations, Oct 2013)



There is an increasing body of literature on encouraging tele-reading outcomes and the spread to mobile phones which we will keep posting and hopefully add to! CLICK HERE for what we have so far. 

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