Using Patient Navigation to Reduce Time to Diagnosis of Breast Cancer in Uganda.

PURPOSE: The Ugandan Ministry of Health adopted BI-RADS as standard of care in 2016. The authors performed a medical audit of breast ultrasound practices at four tertiary-level hospitals to assess interpretive performance. The authors also determined the effect of a low-cost navigation program linking breast imaging and pathology on the percentage of patients completing diagnostic care. METHODS: The authors retrieved 966 consecutive diagnostic breast ultrasound reports, with complete data, for studies performed on women aged >18 years presenting with symptoms of breast cancer between 2018 and 2020 from participating hospitals. Ultrasound results were linked to tumor registries and patient follow-up. A medical audit was performed according to the ACR's BI-RADS Atlas, fifth edition, and results were compared with those of a prior audit performed in 2013. At Mulago Hospital, an intervention was piloted on the basis of patient navigation, cost sharing, and same-day imaging, tissue sampling, and pathology. RESULTS: In total, 888 breast ultrasound examinations (91.9%) were eligible for inclusion. Compared with 2013, the postintervention cancer detection rate increased from 38 to 148.7 cancers per 1,000 examinations, positive predictive value 2 from 29.6% to 48.9%, and positive predictive value 3 from 62.7% to 79.9%. Specificity decreased from 90.5% to 87.7% and sensitivity from 92.3% to 81.1%. The mean time from tissue sampling to receipt of a diagnosis decreased from 60 to 7 days. The intervention increased the percentage of patients completing diagnostic care from 0% to 100%. CONCLUSIONS: Efforts to establish a culture of continuous quality improvement in breast ultrasound require robust data collection that links imaging results to pathology and patient follow-up. Interpretive performance met BI-RADS benchmarks for palpable masses, except sensitivity. This resource-appropriate strategy linking imaging, tissue sampling, and pathology interpretation decreased time to diagnosis and rates of loss to follow-up and improved the precision of the audit.

Observer agreement in single computerized tomography use for diagnosing paediatric head and neck malignancies at Uganda Cancer Institute.

BACKGROUND: In the Ugandan setting, investigation for PHNM with CT uses a protocol with both unenhanced and contrast enhanced procedures hence doubling the ionizing radiation exposure. The purpose of this study was to determine the feasibility of single CT procedures in diagnosing PHNM. METHODS: This was a cross-sectional study using CT images from patients, aged fifteen years and below, investigated for head and neck malignancies at the Uganda Cancer Institute. Three radiologists, observers A, B and C, with 12, 5 and 2 years of experience, respectively, participated in the study. They independently reported contrast enhanced images (protocol A), unenhanced images (protocol B), then both unenhanced and contrast enhanced images (protocol C) in 2 months intervals. Inter- and intra- observer agreement was determined using Gwen's Agreement coefficient. RESULTS: Seventy-three CT scans of 36 boys and 37 girls, with a median age of 9 (3-13) years, were used. Intra-and inter-observer agreement on primary tumour location ranged from substantial to almost perfect with the highest intra-observer agreement observed when protocols A and C were compared. Inter-observer agreement for tumour calcifications was substantial for protocol A. Observers A and C demonstrated an almost perfect intra-observer agreement when protocols A and C were compared. There was a substantial inter-observer agreement on diagnosis for all protocols. CONCLUSIONS: In our setting and examining a limited number of CT images, we demonstrated that contrast-enhanced CT scans provide sufficient information with no evidence of additional value of unenhanced images. Using contrast-enhanced images alone reduced the radiation exposure significantly.

Chest X-ray findings in drug-sensitive and drug-resistant pulmonary tuberculosis patients in Uganda.

Background: Tuberculosis (TB) is one of the leading causes of death worldwide. Radiology has an important role in the diagnosis of both drug-sensitive (DS) and rifampicin-resistant (RR) pulmonary TB (PTB). This study aimed to compare the chest x-ray (CXR) patterns of microbiologically confirmed DS and RR PTB cases stratified by HIV serostatus in Uganda. Methods: We conducted a hospital-based retrospective study at the Mulago National Referral Hospital (MNRH) TB wards. All participants had a microbiologically confirmed diagnosis of PTB. CXR findings extracted included infiltrates, consolidation, cavity, fibrosis, bronchiectasis, atelectasis, and other non-lung parenchymal findings. All films were examined by two independent radiologists blinded to the clinical diagnosis. Results: We analyzed CXR findings of 165 participants: 139 DS- and 26 RR-TB cases. The majority (n = 118, 71.7%) of the participants were seronegative for HIV. Overall, 5/165 (3%) participants had normal CXR. There was no statistically significant difference in the proportion of participants with consolidations (74.8% versus 88.5%; p = 0.203), bronchopneumonic opacities (56.1% versus 42.3%, p = 0.207) and cavities (38.1% versus 46.2%, p = 0.514), across drug susceptibility status (DS versus RR TB). Among HIV-infected participants, consolidations were predominantly in the middle lung zone in the DS TB group and in the lower lung zone in the RR TB group (42.5% versus 12.8%, p = 0.66). HIV-infected participants with RR TB had statistically significantly larger cavity sizes compared to their HIV uninfected counterparts with RR TB (7.7 ± 6.8 cm versus 4.2 ± 1.3 cm, p = 0.004). Conclusions: We observed that a vast majority of participants had similar CXR changes, irrespective of drug susceptibility status. However, HIV-infected RR PTB had larger cavities.The diagnostic utility of cavity sizes for the differentiation of HIV-infected and non-infected RR TB could be investigated further.

Zenker's diverticulum in an 85-year-old Ugandan man.

BACKGROUND: Zenker's diverticulum (ZD) is an uncommon disorder due to an outpouching of tissue through the Killian triangle that is thought to be caused by dysfunction of the cricopharyngeal muscle. CASE PRESENTATION: An 85-year-old male patient presented with odynophagia and dysphagia of initially solid food followed by fluids that was associated with a significant weight loss over a one-year period. Barium swallow videofluoroscopy demonstrated a posterior outpouching of proximal esophagus that was 2 cm from the epiglottis. With the diagnosis of medium sized ZD, the patient underwent endoscopy guided diverticulotomy. Six months after the procedure, he was asymptomatic and had gained weight. CONCLUSIONS: Dysphagia and weight loss raises a clinical suspicion for a malignancy. Barium swallow examination is an inexpensive method for the diagnosis of ZD.

Breast cancer early detection and diagnostic capacity in Uganda.

BACKGROUND: Greater than 80% of women presenting for breast cancer treatment in Uganda have late-stage disease, which is attributable to a dysfunctional referral system and a lack of recognition of the early signs and symptoms among primary health care providers, and compounded by the poor infrastructure and inadequate human capacity. Improving the breast health care system requires a systemic approach beginning with situational analysis to identify systematic gaps that prevent sustainable improvements in outcome. METHODS: The authors performed a situational analysis of the breast health care system using methods developed by the Breast Health Global Initiative. Based on their findings, they developed a series of recommendations for strengthening the health system for the early diagnosis of breast cancer based on clinical detection, referral, tissue sampling, and diagnosis. RESULTS: Deficits in the recognition of breast cancer signs and symptoms, the underuse of clinical breast examination as a diagnostic and/or screening tool, the centralization of diagnostic tests (radiology and pathology), reliance on excisional biopsies rather than needle biopsies, and a lack of trained professionals and knowledge of the referral system all contribute to significant health system delays. CONCLUSIONS: To strengthen referral networks and improve the early diagnosis of breast cancer in Uganda, national referral hospitals should provide educational programs to primary health care providers in community health centers (CHCs), at which the majority of women first present with symptoms. At secondary district-level facilities in which imaging and tissue sampling can be performed, the capacity for diagnostic testing could be increased through task shifting of basic interpretation (abnormal vs normal) from specialists to nonspecialists using networking technology to facilitate remote oversight from specialists at the national referral hospitals.

A phased approach to implementing the Breast Imaging Reporting and Data System (BI-RADS) in low-income and middle-income countries.

BACKGROUND: Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI-RADS), to improve system performance. In low-income and middle-income countries, evolving diagnostic programs have insufficient resources to either fully implement BI-RADS or to periodically evaluate the program's performance, which is a necessary component of BI-RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance. METHODS: The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI-RADS within the context of a limited-resource setting. RESULTS: The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI-RADS should occur after performance and quality metrics have been met. CONCLUSIONS: Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings.

Primary Intradural Extramedullary Spinal Burkitt's Lymphoma: A Case Report.

BACKGROUND: Non-Hodgkin's lymphoma (NHL) rarely involves the spine primarily, and if it does, is almost always associated with advanced disease. CASE PRESENTATION: An 8-year-old male presented with a one month history of nuchal pain followed by stiffness and rapidly progressive upper and lower limb weakness. He was seronegative for HIV and EBV. Computed tomography myelogram and magnetic resonance imaging of the cervical and thoracic spine showed a long segment (C2 to T1) complete absence of cerebrospinal fluid signal and mildly enhancing intradural extramedullary lesion with an extradural and right paravertebral muscle extension, respectively. Post-excision biopsy histopathology and immunohistochemistry confirmed the diagnosis of a CD 10+, CD20+, CD45+, Bcl-2+, Ki67+, and EBER in situ hybridization for EBV negative, Burkitt's lymphoma (BL). Cytogenetic analysis showed chromosomal translocations of 8q24. CHOP plus intrathecal cytarabine, methotrexate was given as chemotherapy regimen. 1.8 grays (Gy) per fraction to the local area for an average total dose of 36 Gy was given with a resultant significant clinical improvement. CONCLUSION: Though considered uncommon spinal canal tumors, BL should be in the differential diagnosis, if multilevel involvement is demonstrated on imaging.

Modifiable patient-related barriers and their association with breast cancer detection practices among Ugandan women without a diagnosis of breast cancer.

Most women with breast cancer in sub-Saharan Africa (SSA) are diagnosed with late-staged disease. The current study assesses patient-related barriers among women from a general SSA population to better understand how patient-related barriers contribute to diagnostic delays. Using convenience-based sampling, 401 Ugandan women without breast cancer were surveyed to determine how prior participation in cancer detection practices correlate with patient-related barriers to prompt diagnosis. In a predominantly poor (76%) and rural population (75%), the median age of the participants was 38. Of the women surveyed, 155 (46%) had prior exposure to breast cancer education, 92 (27%) performed breast self-examination (BSE) and 68 (20%) had undergone a recent clinical breast examination (CBE), breast ultrasound or breast biopsy. The most commonly identified barriers to prompt diagnosis were knowledge deficits regarding early diagnosis (79%), economic barriers to accessing care (68%), fear (37%) and poor social support (24%). However, only women who reported knowledge deficits-a modifiable barrier-were less likely to participate in cancer detection practices (p<0.05). Women in urban and rural areas were similarly likely to report economic barriers, knowledge deficits and/or poor social support, but rural women were less likely than urban women to have received breast cancer education and/or perform BSE (p<0.001). Women who have had prior breast cancer education (p<0.001) and/or who perform BSE (p = 0.02) were more likely to know where she can go to receive a diagnostic breast evaluation. These findings suggest that SSA countries developing early breast cancer detection programs should specifically address modifiable knowledge deficits among women less likely to achieve a diagnostic work-up to reduce diagnostic delays and improve breast cancer outcomes.

Abnormal Admission Chest X-Ray and MEWS as ICU Outcome Predictors in a Sub-Saharan Tertiary Hospital: A Prospective Observational Study.

Background. Critical care in Uganda is a neglected speciality and deemed costly with limited funding/prioritization. We studied admission X-ray and MEWS as mortality predictors of ICU patients requiring mechanical ventilation. Materials and Methods. We did a cross-sectional study in Mulago Hospital ICU and 87 patients for mechanical ventilation were recruited with mortality as the outcome of interest. Chest X-ray results were the main independent variable and MEWS was also gotten for all patients. Results. We recruited 87 patients; most were males (60.92%), aged between 16 and 45 years (59.77%), and most admissions for mechanical ventilation were from the Trauma Unit (30.77%). Forty-one (47.13%) of the 87 patients died and of these 34 (53.13%) had an abnormal CXR with an insignificant IRR = 1.75 (0.90-3.38) (p = 0.062). Patients with MEWS ≥ 5 (p values = 0.018) and/or having an abnormal superior mediastinum (p values = 0.013) showed a positive association with mortality while having a MEWS ≥ 5 had an incidence risk ratio = 3.29 (1.00-12.02) (p = 0.018). MEWS was a good predictor of mortality (predictive value = 0.6739). Conclusion. Trauma (31%) caused most ICU admissions, having an abnormal admission chest X-rays positively associated with mortality and a high MEWS was also a good predictor of mortality.

Improving Breast Ultrasound Interpretation in Uganda Using a Condensed Breast Imaging Reporting and Data System.

RATIONALE AND OBJECTIVES: This study aimed to determine whether a 2-day educational course using a condensed Breast Imaging Reporting and Data System (condensed BI-RADS) improved the accuracy of Ugandan healthcare workers interpreting breast ultrasound. MATERIALS AND METHODS: The target audience of this intervention was Ugandan healthcare workers involved in performing, interpreting, or acting on the results of breast ultrasound. The educational course consisted of a pretest knowledge assessment, a series of lectures on breast imaging interpretation and standardized reporting using a condensed BI-RADS, and a posttest knowledge assessment. Participants interpreted 53 different ultrasound test cases by selecting the finding type, descriptors for masses, and recommendations. We compared the percent correct on the pretest and posttest based on occupation and training level. RESULTS: Sixty-one Ugandan healthcare workers participated in this study, including 13 radiologists, 13 other physicians, 12 technologists, and 23 midlevel providers. Most groups improved in identifying the finding type (P < 0.05). All occupations showed improved use of descriptive terms for the shape and internal echogenicity of masses (P < 0.05). Most groups showed significant improvement in recommendations for normal and benign findings with a corresponding reduction in biopsy recommendations. CONCLUSIONS: Targeted breast ultrasound education using a condensed BI-RADS improved the interpretive performance of healthcare workers and was particularly successful in reducing the frequency of unnecessary biopsies for normal and benign findings. Multimodal educational efforts to improve accuracy and management of breast ultrasound findings may augment breast cancer early detection efforts in resource-limited settings.