A teleradiology network for the improvement of healthcare and patient management in the developing countries of the African continent.

INTRODUCTION: Africa is the second-largest continent on Earth in terms of both size and population. However, inaccessibility and shortfall of trained radiologists impede the delivery of adequate healthcare to such a large population. Teleradiology holds considerable potential in improving patient outcomes and healthcare delivery in African nations by furnishing timely interpretation of radiological examinations, particularly in those areas where there is a particular scarcity of radiologists. The aim of the present study was to assess the impact of teleradiology in the improvement of healthcare and patient management in the developing countries of the African continent. METHODS: In this retrospective study, from January 2017 and December 2022, the scans of a cohort of patients from eight African countries were uploaded to the teleradiology cloud server and interpreted by board certified radiologists empanelled by a teleradiology service provider. RESULTS: The telehealth model proposed in the study was seen to provide timely and quality reporting of 58,223 scans of 39,513 patients with a mean turn-around-time (TAT) of 2.46 h 95 % CI (2.44-2.48). DISCUSSION: A dedicated teleradiology model designed in this study allowed the interpretation and analysis of the scans of the cohort of patients from hospitals in African countries by teleradiologists via high quality DICOM-image transfer over a cloud-based platform. The outcomes of our investigation reflect that teleradiology provides an effective solution for early diagnosis/interpretation of examinations performed in Africa. Further, the currently proposed teleradiology model may be used for other developing countries across the world to improve quality of care.

Utilization of Teleradiology by Intensive Care Units: A Cohort Study.

Aim and background: Imaging is indispensable to the diagnostic and treatment process. By facilitating access to rapid timely image interpretation, teleradiology plays a prominent role in improving access, quality of critical care, and management of the patients in intensive care units (ICU). The aim of the study is to investigate the role of teleradiology in ICU patient care and management. Materials and methods: In our study, a total of 22,081 studies of a cohort of 14,900 patients which had been transmitted from intensive care units of 80 hospitals located across the United States of America through a teleradiology reporting workflow, were interpreted by the American Board Certified Radiologists empanelled by a teleradiology service provider, located in India. Results: Among all modalities, the highest percentage of studies performed were computed tomography scan (47%) followed by radiographs (37.22%). Out of 22,081 cases under the study, 16,582 cases were reported during nighttime with a mean turnaround time (TAT) of 46.66 minutes 95% CI (46.27-47.04) while 5,499 cases were reported during daytime with a mean TAT of 44.66 minutes 95% CI (45.40-43.92). Conclusion: Setting up teleradiology service connectivity with a teleradiology service provider located in India, providing high-quality diagnostic interpretations and lower turnaround time with the ICUs in the US hospitals reduces the interval to intervention time and leads to efficient patient care management. Moreover, it also provides time advantage for US hospitals when on-site radiologists at night are unable to provide immediate coverage. Clinical significance: The ICU teleradiology service model designed in the study would greatly help overcome the shortfall of radiologists in the hospitals, provide better patient management and care by quality reporting in short turnaround time, not only during daytime but also in the night hours or on holidays when on-site radiologists are unable to provide immediate coverage. How to cite this article: Rao P, Mathur N, Kalyanpur A. Utilization of Teleradiology by Intensive Care Units: A Cohort Study. Indian J Crit Care Med 2024;28(1):20-25.

Teleradiology and technology innovations in radiology: status in India and its role in increasing access to primary health care.

Background: There is an inequitable distribution of radiology facilities in India. This scoping review aimed at mapping the available technology instruments to improve access to imaging at primary health care; to identify the facilitators and barriers, and the knowledge gaps for widespread adaptation of technology solutions. Methods: A search was conducted using broad inclusive terms non-specific to subtypes of medical imaging devices or informatics. Work published in the English language between 2005 and 2022, conducted primarily in India, and with full manuscripts were included. Two authors independently screened the abstracts against the inclusion criteria for full-text review and a senior author settled discrepancies. Data were extracted using DistillerSR software. Findings: 43 original articles and 52 non-academic materials were finally reviewed. The data was from 10 Indian states with n = 9 from rural settings. The broad trends in original articles were: connectivity using teleradiology (n = 7), mobile digital imaging units (n = 9), artificial intelligence (n = 16); mobile devices and smartphone applications (n = 7); data security (n = 7) and web-based technology (n = 2); public-private partnership (n = 9); cost (n = 2); concordance (n = 19); evaluation (n = 4); implementation (n = 2). Interpretation: Available evidence suggests that teleradiology when combined with AI and mobile digital imaging units can address radiologist shortages; strengthen programs aimed at population screening and emergency care. However, there is insufficient data on the scale of teleradiology networks within India; needs assessment; cost; facilitators, and barriers for implementation of technologies solutions in primary healthcare settings. Regulations governing quality standards, data protection, and confidentiality are unclear. Funding: The authors are The Lancet Citizen's Commission fellows. The Lancet Commission has received financial support from the Lakshmi Mittal and Family South Asia Institute, Harvard University; Christian Medical College, Vellore (CMC), Vellore; Azim Premji Foundation, Infosys; Kirloskar Systems Ltd.; Mahindra & Mahindra Ltd.; Rohini Nilekani Philanthropies; and Serum Institute of India. The views expressed are those of the author(s) and not necessarily those of the Lancet Citizens' Commission or its partners.

Validation of expert system enhanced deep learning algorithm for automated screening for COVID-Pneumonia on chest X-rays.

SARS-CoV2 pandemic exposed the limitations of artificial intelligence based medical imaging systems. Earlier in the pandemic, the absence of sufficient training data prevented effective deep learning (DL) solutions for the diagnosis of COVID-19 based on X-Ray data. Here, addressing the lacunae in existing literature and algorithms with the paucity of initial training data; we describe CovBaseAI, an explainable tool using an ensemble of three DL models and an expert decision system (EDS) for COVID-Pneumonia diagnosis, trained entirely on pre-COVID-19 datasets. The performance and explainability of CovBaseAI was primarily validated on two independent datasets. Firstly, 1401 randomly selected CxR from an Indian quarantine center to assess effectiveness in excluding radiological COVID-Pneumonia requiring higher care. Second, curated dataset; 434 RT-PCR positive cases and 471 non-COVID/Normal historical scans, to assess performance in advanced medical settings. CovBaseAI had an accuracy of 87% with a negative predictive value of 98% in the quarantine-center data. However, sensitivity was 0.66-0.90 taking RT-PCR/radiologist opinion as ground truth. This work provides new insights on the usage of EDS with DL methods and the ability of algorithms to confidently predict COVID-Pneumonia while reinforcing the established learning; that benchmarking based on RT-PCR may not serve as reliable ground truth in radiological diagnosis. Such tools can pave the path for multi-modal high throughput detection of COVID-Pneumonia in screening and referral.

Interobserver Variation in Response Evaluation Criteria in Solid Tumors 1.1.

PURPOSE: Response Evaluation Criteria in Solid Tumors (RECIST 1.1) is the gold standard for imaging response evaluation in cancer trials. We sought to evaluate consistency of applying RECIST 1.1 between 2 conventionally trained radiologists, designated as A and B; identify reasons for variation; and reconcile these differences for future studies. METHODS: The study was approved as an institutional quality check exercise. Since no identifiable patient data was collected or used, a waiver of informed consent was granted. Imaging case report forms of a concluded multicentric breast cancer trial were retrospectively reviewed. Cohen's kappa was used to rate interobserver agreement in Response Evaluation Data (target response, nontarget response, new lesions, overall response). Significant variations were reassessed by a senior radiologist to extrapolate reasons for disagreement. Methods to improve agreement were similarly ascertained. RESULTS: Sixty one cases with total of 82 data-pairs were evaluated (35 data-pairs in visit 5, 47 in visit 9). Both radiologists showed moderate agreement in target response (n = 82; ĸ = 0.477; 95% confidence interval [CI]: 0.314-0.640-), nontarget response (n = 82; ĸ = 0.578; 95% CI: 0.213-0.944) and overall response evaluation in both visits (n = 82; ĸ = 0.510; 95% CI: 0.344-0.676). Further assessment demonstrated "Prevalence effect" of Kappa in some cases which led to underestimation of agreement. Percent agreement of overall response was 74.39% while percent variation was 25.6%. Differences in interpreting RECIST 1.1 and in radiological image interpretation were the primary sources of variation. The commonest overall response was "Partial Response" (Rad A:45/82; Rad B:63/82). CONCLUSION: Inspite of moderate interobserver agreement, qualitative interpretation differences in some cases increased interobserver variability. Protocols such as Adjudication, to reduce easily avoidable inconsistencies are or should be a part of the Standard Operating Procedure in imaging institutions. Based on our findings, a standard checklist has been developed to help reduce the interpretation error-margin for future studies. Such check-lists may improve interobserver agreement in the preadjudication phase thereby improving quality of results and reducing adjudication per case ratio. CLINICAL RELEVANCE: Improving data reliability when using RECIST 1.1 will reflect in better cancer clinical trial outcomes. A checklist can be of use to imaging centers to assess and improve their own processes.

Utility of contemporaneous dual read in the setting of emergency teleradiology reporting.

PURPOSE: Emergency radiology requires rapid and accurate interpretation of imaging examinations. Missed findings may lead to adverse outcomes. Double reporting may be used to minimize errors. Limited contemporaneous double reporting may be most efficient and cost-effective, but no data exists. This study is intended to examine the benefits of double reading and identify examinations where this would be most useful. METHODS: In this study, dual reporting was conducted in a parallel reading environment in a teleradiology practice for 3779 radiological procedures performed at two radiology centers in the USA over a period of 4 months. Discrepancies between reads were scored using the ACR peer review scoring system and grouped by modality and body part. Errors were tabulated across the study types, followed by identification of statistically significant differences. The interaction between image number and odds of an error was ascertained. RESULTS: In 145 instances (3.8%; 95 % CI, 3.2-4.4%), double reporting identified errors, leading to report modification. Study type was significantly related to error frequency (p = 0.0001), with higher than average frequencies of error seen for CT abdomen and pelvis and MRI head or spine, but lower than average for CT head, CT spine, and ultrasound. Image number was positively associated with error odds, but was not independently significant in a joint logistic regression model that included study type. CONCLUSION: Dual reporting identifies missed findings in about 1 of 25 emergency studies. This benefit varies substantially across study types and limited double reporting, merits further investigation as a cost-effective practice improvement strategy.

Spectrum of Abdominal Aortic Disease in a Tertiary Health Care Setup: MDCT Based Observational Study.

INTRODUCTION: Abdominal aortic disease is an important cause of clinical disability that requires early detection by imaging methods for prompt and effective management. Understanding regional disease pattern and prevalence has a bearing on healthcare management and resource planning. Non-invasive, conclusive imaging strategy plays an important role in the detection of disease. Multi-Detector Computed Tomography (MDCT) with its technological developments provides affordable, accurate and comprehensive imaging solution. AIM: To evaluate regional demography of abdominal aortic disease spectrum detected using MDCT imaging data in a tertiary hospital. MATERIALS AND METHODS: A descriptive study was conducted based on MDCT imaging data of patients who were investigated with clinical diagnosis of abdominal aortic disease, from March 2008-2010, over a period of 24 months. Patients were examined with the contrast-enhanced MDCT examination. Morphological diagnosis of the aortic disease was based on changes in relative aortic caliber, luminal irregularity, presence of wall calcification, dissection or thrombus and evidence of major branch occlusion. Patients were categorized into four groups based on imaging findings. MDCT information and associated clinical parameters were examined and correlated to management of patient. Descriptive statistical data, namely mean, standard deviation and frequency of disease were evaluated. RESULTS: A total of 90 out of 210 patients (43%) were detected with the abdominal aortic abnormality defined by imaging criteria. Group I, comprising of patients with atherosclerosis -including those with complications, constituted 65.5% of the patients. Group II represented patients with aneurysms (45.5%). Group III, consisting of 32.2% of the patients, contained those with dissections. The rest of the patients, including patients with aorto-arteritis, were classified as group IV. Eight patients with aneurysm and one patient with aorto-arteritis were considered for surgical treatment. Ten patients with dissection underwent endovascular procedure. Rest of the patients was managed conservatively. CONCLUSION: Aortic disease was observed in 43% of investigated patients. Atherosclerosis with and without aortic aneurysm constituted the largest group. MDCT provided comprehensive information about the lesion and associated complications. In view of the wider availability and desired imaging qualities, MDCT provided optimal information for diagnosis and management of aortic pathology. Majority of our patients (90%) were treated conservatively.

The role of teleradiology in emergency radiology provision.

Teleradiology has had a major impact in decreasing report turnaround time, and in improving service levels in the emergency setting. Teleradiology in the emergency setting is usually associated with a strong peer review and quality assurance process. It has generated a cadre of specialized generalists, who excel in acute care interpretation. Hence report quality is enhanced. By using the centralized reading room coupled with the night-day model, radiologist productivity is increased and healthcare costs are reduced. Communication levels between clinicians and radiologists remain high, commensurate with on-site radiology. The cons are related to insufficient adherence to regulations, corporatization and predatory practices, which are economic and investor-driven rather than in the interests of patient care. Insufficient clinical history and large imaging datasets present a challenge.

Voice recognition is here comma like it or not period.

Voice recognition (VR) technology needs improvement, but is as integral to the current practice of radiology as Radiology Information Systems and Picture Archival and Communication Systems. In the 1990s, the radiology community gave VR technology a rather lukewarm reception, but since then it has emerged as the predominant method of radiology reporting in the United States. In this article, we examine how VR technology works, outline the positive and negative aspects of VR technology on work flow, identify common VR transcription errors and review the discussion on VR adoption in the recent literature. We add to the discussion our personal experiences in an international teleradiology group.

Utility of mobile devices in the computerized tomography evaluation of intracranial hemorrhage.

AIM: To evaluate the utility of a mobile device to detect and assess intracranial hemorrhage (ICH) on head computed tomographys (CT) performed in the emergency setting. MATERIALS AND METHODS: 100 head CT scans were randomly selected from our emergency radiology database and anonymized for patient demographics and clinical history. The studies were independently interpreted by two experienced radiologists in a blinded manner, initially on a mobile device (iPad, Apple computers) and subsequently, at an interval of one week, on a regular desktop workstation. Evaluation was directed towards detection, localization and characterization of hemorrhage. The results were assessed for accuracy, sensitivity, specificity and positive predictive value. Statistical significance was ascertained using Fisher's exact test. RESULTS: 27 of the examinations were positive for ICH, of which 11 had multiple hemorrhages. Of these there were 17 subdural, 18 intraparenchymal, 8 subarachnoid, 4 intraventricular and 2 extradural hemorrhages. In 96 of the studies there was complete concurrence between the iPad and desktop interpretations for both radiologists. Of 49 hemorrhages, 48 were accurately detected on the iPad by one of the radiologists. In the remaining case, a tiny intraventricular hemorrhage was missed by both radiologists on the iPad as well as on the workstation, indicating that the miss was more likely related to the very small size of the hemorrhage than the viewer used. CONCLUSION: We conclude that in the emergency setting, a mobile device with appropriate web-based pictue archiving and communication system (PACS) is effective in the detection of intracranial hemorrhage present on head CT.

Radiology and the mobile device: Radiology in motion.

The use of mobile devices is revolutionizing the way we communicate, interact, are entertained, and organize our lives. With healthcare in general and radiology in particular becoming increasingly digital, the use of such devices in radiologic practice is inevitable. This article reviews the current status of the use of mobile devices in the clinical practice of radiology, namely in emergency teleradiology. Technical parameters such as luminance and resolution are discussed. The article also discusses the benefits of such mobility vis-à-vis the current limitations of the technologies available.

Accurate prostate volume estimation using multifeature active shape models on T2-weighted MRI.

RATIONALE AND OBJECTIVES: Accurate prostate volume estimation is useful for calculating prostate-specific antigen density and in evaluating posttreatment response. In the clinic, prostate volume estimation involves modeling the prostate as an ellipsoid or a spheroid from transrectal ultrasound, or T2-weighted magnetic resonance imaging (MRI). However, this requires some degree of manual intervention, and may not always yield accurate estimates. In this article, we present a multifeature active shape model (MFA) based segmentation scheme for estimating prostate volume from in vivo T2-weighted MRI. MATERIALS AND METHODS: We aim to automatically determine the location of the prostate boundary on in vivo T2-weighted MRI, and subsequently determine the area of the prostate on each slice. The resulting planimetric areas are aggregated to yield the volume of the prostate for a given patient. Using a set of training images, the MFA learns the most discriminating statistical texture descriptors of the prostate boundary via a forward feature selection algorithm. After identification of the optimal image features, the MFA is deformed to accurately fit the prostate border. An expert radiologist segmented the prostate boundary on each slice and the planimetric aggregation of the enclosed areas yielded the ground truth prostate volume estimate. The volume estimation obtained via the MFA was then compared against volume estimations obtained via the ellipsoidal, Myschetzky, and prolated spheroids models. RESULTS: We evaluated our MFA volume estimation method on a total 45 T2-weighted in vivo MRI studies, corresponding to both 1.5 Tesla and 3.0 Tesla field strengths. The results revealed that the ellipsoidal, Myschetzky, and prolate spheroid models overestimated prostate volumes, with volume fractions of 1.14, 1.53, and 1.96, respectively. By comparison, the MFA yielded a mean volume fraction of 1.05, evaluated using a fivefold cross-validation scheme. A correlation with the ground truth volume estimations showed that the MFA had an r(2) value of 0.82, whereas the clinical volume estimation schemes had a maximum value of 0.70. CONCLUSIONS: Our MFA scheme involves minimal user intervention, is computationally efficient and results in volume estimations more accurate than state of the art clinical models.

Double reading of radiological examinations in Norway.

BACKGROUND: Double reading of images is a part of the quality assurance activities at many radiological centers. PURPOSE: To investigate the extent of and routines for double reading in Norway and the institutional heads' attitudes toward double reading. MATERIAL AND METHODS: A questionnaire was addressed to the heads of all radiological institutions in Norway. The questionnaire concerned staffing, examinations performed, extent of double reading per imaging modality (except mammography screening), guidelines for double reading, checks of completed radiology reports, frequency of regular quality assurance meetings to discuss missed findings, and the heads' attitudes toward double reading. RESULTS: The response rate was 73% (53/73). The percentage across imaging modalities of examinations being double read was 41% overall: 56% at university hospitals, 37% at local hospitals, and 18% at private centers. Double reading was most common for positron emission tomography (PET)/PET-computed tomography (CT) examinations (100%), and clinical mammography (91%). Almost all examinations read by residents were double read. Only 15% of institutions had written guidelines for double reading, 15% performed random double readings of completed examinations, and 55% organized regular meetings to discuss missed findings. Forty-six percent of the institutional heads wanted an increased use of double reading. CONCLUSION: Double reading is common in Norway, especially in residency training, mammography, and PET/PET-CT. It is less common at private centers. Established routines for double reading are scarce. Many institutional heads want more double reading. The potential of double reading to assure quality in radiology should be better exploited.

A magnetic resonance spectroscopy driven initialization scheme for active shape model based prostate segmentation.

Segmentation of the prostate boundary on clinical images is useful in a large number of applications including calculation of prostate volume pre- and post-treatment, to detect extra-capsular spread, and for creating patient-specific anatomical models. Manual segmentation of the prostate boundary is, however, time consuming and subject to inter- and intra-reader variability. T2-weighted (T2-w) magnetic resonance (MR) structural imaging (MRI) and MR spectroscopy (MRS) have recently emerged as promising modalities for detection of prostate cancer in vivo. MRS data consists of spectral signals measuring relative metabolic concentrations, and the metavoxels near the prostate have distinct spectral signals from metavoxels outside the prostate. Active Shape Models (ASM's) have become very popular segmentation methods for biomedical imagery. However, ASMs require careful initialization and are extremely sensitive to model initialization. The primary contribution of this paper is a scheme to automatically initialize an ASM for prostate segmentation on endorectal in vivo multi-protocol MRI via automated identification of MR spectra that lie within the prostate. A replicated clustering scheme is employed to distinguish prostatic from extra-prostatic MR spectra in the midgland. The spatial locations of the prostate spectra so identified are used as the initial ROI for a 2D ASM. The midgland initializations are used to define a ROI that is then scaled in 3D to cover the base and apex of the prostate. A multi-feature ASM employing statistical texture features is then used to drive the edge detection instead of just image intensity information alone. Quantitative comparison with another recent ASM initialization method by Cosio showed that our scheme resulted in a superior average segmentation performance on a total of 388 2D MRI sections obtained from 32 3D endorectal in vivo patient studies. Initialization of a 2D ASM via our MRS-based clustering scheme resulted in an average overlap accuracy (true positive ratio) of 0.60, while the scheme of Cosio yielded a corresponding average accuracy of 0.56 over 388 2D MR image sections. During an ASM segmentation, using no initialization resulted in an overlap of 0.53, using the Cosio based methodology resulted in an overlap of 0.60, and using the MRS-based methodology resulted in an overlap of 0.67, with a paired Student's t-test indicating statistical significance to a high degree for all results. We also show that the final ASM segmentation result is highly correlated (as high as 0.90) to the initialization scheme.

Systematic survey of discrepancy rates in an international teleradiology service.

International teleradiology services (ITS) to the United States are based on the principle of deploying American board-certified radiologists across global time zones to optimally distribute the workload. While errors may be reduced by circumventing the traditional night call, there is limited evidence on the actual error rates of teleradiology groups. We have a comprehensive quality assurance (QA) process in our practice, which includes a review of discrepancies between preliminary reports and the final reports by the on-site radiologists. We analyzed the discrepancy QA data to determine the error rates. Archived QA data for 126,449 cases over a period of 1 year (2008) were analyzed for the discrepancy rate, nature of errors, and possible contributory factors. The scores ranged from 0 (no error) to 5 (clinically significant in the acute setting) based on the level of clinical significance. A novel modified Lorenz plot was used to estimate the degree of underreporting and to estimate the true error rate. An internal review of 200 cases was performed to validate the findings. Of the total, there was a total of 227 confirmed errors (0.18%, 95% CI, 0.16 to 0.20). Of these, the majority were levels 2 and 3 (minor error and error of long-term significance but not in the acute setting). Even after correction for underreporting, error rates were less than 1% for clinically significant errors. ITS is associated with very low rates of clinically significant errors. Due to limited feedback, particularly for minor errors, an internal review is important.

Role of multidetector computed tomography in evaluating complications following endovascular repair of aortic aneurysm.

OBJECTIVE: To study the role of multidetector computed tomography (MDCT) in evaluating various complications following endovascular stenting of aortic aneurysms. MATERIALS AND METHODS: Over a period of 2 years (June 2005 to June 2007), 50 patients with aortic aneurysm on computed tomography (CT) angiogram were prospectively studied. Images were acquired on a 64 slice multidetector row CT scanner (GE-LightSpeed VCT) after intravenous administration of nonionic iodinated contrast. Nineteen patients underwent endovascular stent-graft repair based on their medical and surgical risk factors. Stent-graft related complications were recorded by CT angiography and analyzed using descriptive statistics. RESULTS: Most common complication related to the endovascular stent-graft placement was endoleak (44.4%), followed by puncture site hematoma (27.8%), thrombotic occlusion of a limb of the bifurcated stent graft, kinking of the stent-graft, and difficult catheterization with intimal tear in the common iliac artery were 5.6% each. Poststent diameter of the aneurysm was an important predictor of endoleaks. All the patients with either increase or no change in the aneurysm size had endoleaks. CONCLUSION: MDCT angiography is an important modality in identifying, describing, and following up the various complications following endovascular repair of aortic aneurysms, endoleaks being the most common complication. Decrease in the poststent diameter of the aneurysm suggested a good outcome.

Teleradiology in an inaccessible area of northern India.

Teleradiology can be used to provide health care to rural populations, especially where there is a scarcity of resources, including on-site radiologists. We have established a network link between a commercial teleradiology provider in Bangalore, south India and the Ramakrishna Mission Hospital (RKMH), located over 3000 km away in the north east of India. Image files were transferred to Bangalore via an ADSL connection using secure file transfer protocol. In the 12-month period beginning in August 2007, a total of 962 studies was sent to Bangalore from the RKMH. The average turnaround time for the report to reach the hospital once the images had been received in Bangalore was six hours for non-emergency cases. For emergency cases the turnaround time was consistently below 30 minutes. Because the RKMH was a charitable institution providing rural patients with free or low-cost treatment, no charge was made for the reporting. Our experience demonstrates that remote implementation of teleradiology is possible in rural India. The service has proved valuable for the remote hospital concerned.