Figure 8. Images taken on digital x-ray units can often be sent via direct export to DICOM or JPEG. However, majority of volume for teleradiology are non-digital !lms. As a result digital photography using cameras is heavily utilized.8A. Viewboxes are not always available but referring physicians do their best.8B. CT scan images are also not always available via DICOM but certain questions can be answered via digital photography of the !lm. In this case, patient has di"use metastatic prostate cancer. 8C. Digital photograph of a chest radiograph hanging on a viewbox.

Sung H Kim, MD; Subba R Digumarthy, MD; Sjirk J Westra, MD; Randheer Shailam, MD; Parul Penkar, MBBS; Garry Choy, MDLessons Learned in Teleradiology for Global Health: Providing Imaging Services to Rwanda, Africa

Summary

Radiology can play a signi!cant role in global health.

While diagnostic radiology remains a key component in practice of medicine even in resource-poor settings of the developing world, radiologists are seldom involved when compared to the e"orts of other medical specialties.

Numerous non-pro!t organizations and volunteer physicians in !elds outside of imaging are looking to radiologists to participate and play a critical role in providing much needed teleradiology services.

Informatics tools are low cost and ubiquitous, enabling access to high quality medical imaging globally for those in underserved regions.

For more information on our work and if you are interested in participating, please contact – Garry Choy, MD Mass General Imaging gchoy@partners.org 617-383-9729 (mobile)

Purpose/Aim

Access to medical imaging expertise in the developing world is limited. Radiography & ultrasound has emerged as a diagnostic tool in certain resource-poor settings in developing nations. This exhibit aims to demonstrate how a pro-bono teleradiology service can be developed, executed, & evaluated via the example of our experience in Rwanda, Africa. Content Organization

In our exhibit, we will review key elements in teleradiology for resource-poor settings: Low-cost Teleradiology Informatics Solutions

r own secure image sharing platform

Policy and Legal issues

Legal and policy issues in global health work often center around two major areas: medicolegal risk and institutional research compliance. While minimal, there is still a low risk for malpractice liability. However, fortunately issues of jurisdiction and good Samaritan laws will often protect healthcare professionals in volunteer activities for global health. It is important to check with your insurance provider. Our insurance provider has provided additional coverage for outreach and charitable medical practices.

Additionally, needs assessments and research activities that arise from work abroad need to also be actively cleared not only by our local IRB but also the

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In Rwanda, nearly all cases are referred to our service via Partners in Health, but

we also provide radiology services to other NGOs and organizations including:

Recruiting Volunteer Radiologists, Technologists,

and Imaging Experts:

Radiologists and technologists from various private practices and academic institutions.

Recent members come from various areas including: Massachusetts General Hospital, Boston, MA; Mount Auburn Hospital, Cambridge, MA; Mayo Clinic, Rochester, MN; Columbia University Medical Center, New York, NY; Brown University, Providence, RI; and National Jewish Medical and Research Center, Denver, CO.

Informatics professionals in industry and in academic settings.

Academic and industry collaboration helpful for providing resources and expertise.

Educational E"orts in Rwanda, Africa

Review of Teleradiology Cases from Rwanda, Africa

Case 4. Patient SG is a 45-year-old male who presented with vague abdominal pain. Plain !lm 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

pending but surgeons found a perforated bowel from a large obstructing small bowel tumor.

Case 1. 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

the left femur showed a large area of permeative lytic lesion extending from mid diaphysis to distal

the diaphysis of the femur with Codman's triangle

malignancies such as osteosarcoma, primary lymphoma of bone, Ewing's sarcoma as well as osteomyelitis with a large associated infected collection. As primary malignancy was inthe di"erential diagnosis, MRI was recommended to look for any skipped lesions and the patient was sent to Kigali for the study. No skipped lesion was seen and a biopsy was performed which showed focal myositis without evidence of

Case 2. Patient MM is a 18-year-old female with 6-month history of nonpainful mass in the distal lower

radiographs of the tibia and !bula showed aggressive sunburst periosteal reaction in the mid to distal tibia

consistent with metastatic disease. Unfortunately the patient expired within the year following diagnotic work-up.

Case 3. 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 !lm 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 !lm 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.

Cases are typically sent for

consultation

Case 5. 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 di"erential diagnostic considerations. Due to signi!cant mass e"ect, patient was taken to surgery for treatment/further diagnosis. Diagnosis was neurocysticercosis at the time of surgery.

Case 6. NB is a 3-month-old status post NG tube placement but referring physicians could not !nd the tip and unclear if patient was successful. Radiologists via teleradiology identi!ed tip was coiled in mouth

Case 7. 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 con!rmed liver abscess.