International Radiology Exchange - Lessons in Teleradiology Outreach

1. Lessons Learned in Teleradiology for Global Health - Providing Imaging Services to Rwanda, Africa: Our Experience, Lessons, and Cases in International Outreach Efforts for Acute/Urgent Radiological Conditions Sung H. Kim, MD Stewart Worrell, MD Matt Schmitz, MD Efren Flores, MD Garry Choy, MD

4. Outreach Model Primary International Medical Outreach Organizations NGOs Volunteer Organizations

11. Images Can Be DICOM or JPG/GIF Acquired Via Digital Camera of Actual Film or Console

15. Picasa Cases are organized by folders

16. Picasa Each folder is organized by built-in layout tool

17. Picasa Each JPG or GIF image can be viewed individually

19. YouSendit

20. Mobile-Phone MultiMedia Messaging Service (MMS) Even in resource poor settings, mobile technology is ubiquitous and more frequently available than land-based internet connections Analogous to text messaging, multimedia messaging (MMS) on enabled-cellular phones can transmit multimedia including images, audio, and video to other mobile devices or email accounts

22. DICOM transfer inteleGRID from intelemage

24. Pictured: Ratanakiri Provincial Hospital, Cambodia and x-ray reading room iRadX Partner, Operation Village Health, Center for Connected Health @ Massachusetts General Hospital

25. Cases from Rwanda via Teleradiology (iRadX.org) Autoimmune Hepatitis TB resulting in chronic ureteral stricture/obstruction and marked cortical atrophy Neonatal Pulmonary TB

26. Cases from Haiti via Teleradiology (iRadX.org) TB TB VSD Hirschsprung’s HIV Cholangiopathy Neurocysticercosis

27. Cases from Rwanda via Teleradiology (iRadX.org) Patient VJ is a 14-year-old male with one month history of leg pain. The pain started in the knee and migrated to the distal thigh. The patient had been febrile. (A) and (B) Plain films of the left femur showed a large area of permeative lytic lesion extending from mid diaphysis to distal metaphysic with a possible sequestrum (blue arrow). Biopsy was performed which showed focal myositis without evidence of malignancy. (D) Subsequent 4-month follow-up study showed marked improvement of the soft tissue mass and improving periosteal reaction

28. Cases from Rwanda via Teleradiology (iRadX.org) Patient MM is a 18-year-old female with 6-month history of nonpainful mass in the distal lower leg. She was being treated for osteomyelitis but radiographs were obtained to rule out malignancy. (A) The radiographs of the tibia and fibula showed aggressive sunburst periosteal reaction in the mid to distal tibia with associated mass corresponding to the patient’s photo (B). Diagnosis of osteosarcoma was made and chest imaging was recommended for metastatic work up. (C) Staging chest CT showed multiple nodules consistent with metastatic disease. Unfortunately the patient expired within the year following diagnotic work-up.

29. Cases from Rwanda via Teleradiology (iRadX.org) Patient NG is a 4-year-old patient presenting with fever and seizures. Patient received a CT scan from the nearest major hospital of Kigali. Abscess, parasitic infection, and malignancy were considered. Case was sent from neurosurgeon for second opinion regarding full range of differential diagnostic considerations. Due to significant mass effect, patient was taken to surgery for treatment/further diagnosis. Diagnosis was neurocysticercosis at the time of surgery.

30. Cases from Rwanda via Teleradiology (iRadX.org) Patient DM is a 12-year-old male with back pain for months who also developed left hip pain so that he was unable to walk. Plain film of the pelvis was obtained which showed joint space narrowing and erosion of the left sacroiliac joint. Concern for septic joint was raised based on the film and the clinical team performed aspiration. One liter of purulent material was obtained from the left SI joint. Although no organism was isolated, tuberculosis was presumed at last update.

31. Cases from Rwanda via Teleradiology (iRadX.org) Patient SG is a 45-year-old male who presented with vague abdominal pain. Plain film of the abdomen revealed mass pneumoperitoneum. The case was interpreted within 5 minutes of receipt from Rwanda, Africa. Communication was made to the referring physician and patient was immediately transferred for surgery to evaluate for perforated ulcer versus small bowel obstruction (SBO) with perforation. Pathology is still pending but surgeons found a perforated bowel from a large obstructing small bowel tumor.

32. Cases from Rwanda via Teleradiology (iRadX.org) NB is a 3-month-old status post NG tube placement but referring physicians could not find the tip and unclear if patient was successful. Radiologists via teleradiology identified tip was coiled in mouth

33. Cases from Rwanda via Teleradiology (iRadX.org) CN is a 45-year-old patient with history of HIV with fevers presents with heterogeneous lesion in liver. Ultrasound sweep images and static images provided demonstrating loculated intrahepatic collection. Surgical aspiration confirmed liver abscess.