Research Articles (Radiodiagnosis)

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    Trends in public sector radiological usage in the Western Cape Province, South Africa : 2009–2019
    (AOSIS, 2021-11) Van Wijk, Monica; Barnard, Michelle M.; Fernandez, Amanda; Cloete, Keith; Mukosi, Matodzi; Pitcher, Richard D.
    Background: Although global use of medical imaging has increased significantly, little is known about utilisation trends in low- and middle-income countries (LMICs). Objectives: To evaluate changes over a decade in public sector diagnostic imaging utilisation at provincial level in a middle-income country. Method: A retrospective analysis of medical imaging utilisation in the Western Cape Province of South Africa in 2009 and 2019. Use of conventional radiography, ultrasonography (US), fluoroscopy, CT, MRI, digital subtraction angiography (DSA) and whole-body digital radiography was assessed by total studies and studies/103 people, for the whole province, the rural and metropolitan areas. Mammography utilisation was calculated for every 103 females aged 40–70 years. Results: The provincial population and total imaging investigations increased by 25% and 32%, respectively, whilst studies/103 people increased by 5.5% (256 vs 270/103), with marked variation by modality. Provincial US, CT and MRI utilisation/103 people increased by 111% (20 vs 43/103), 78% (10 vs 18/103) and 32% (1.9 vs 2.5/103) respectively, whilst use of fluoroscopy (3.6 vs 3.7/103) and mammography (14.2 vs 15.9/103 women aged 40–70 years) was steady and plain radiography decreased by 20% (216 vs 196/103). For CT, mammography and fluoroscopy, percentage utilisation increases/103 people were higher in the rural than metropolitan areas. Conclusion: Population growth is the main driver of overall imaging utilisation in our setting. The relatively constant imaging workload per 1000 people, albeit with increasing ultrasound, CT and MR utilisation, and decreasing use of plain radiography, reflects improved provincial imaging infrastructure, and appropriate use of available resources.
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    Magnetic resonance imaging for paediatric retroperitoneal masses : diagnostic accuracy of the claw sign
    (AOSIS, 2021-02) Combrink, Lisa; Beviss-Challinor, Kenneth B.
    Background: The claw sign is advocated as a discriminant of renal versus non-renal origin of tumours. The accuracy of the claw sign on magnetic resonance imaging (MRI) is unknown and is potentially hindered by the inferior spatial resolution and the larger tumour sizes at presentation in developing countries. Objectives: To define and evaluate the claw sign in differentiating renal from non-renal retroperitoneal masses in children undergoing MRI. Methods: A definition of the claw sign was proposed. Magnetic resonance imaging studies, clinical and laboratory records of 53 children were reviewed to test the diagnostic accuracy, inter- and intra-observer reliability. Three tumour–mass interface characteristics, inherent to the claw sign, were tested: (1) a smooth tapering kidney edge blending continuously with the tumour, (2) absence of infolding of the kidney and (3) an obtuse superficial angle. Results: The sensitivity, specificity, negative predictive value and positive predictive values of the claw sign were 97%, 74%, 83% and 94%. The Cohen’s kappa values for intra-rater reliability were 0.72 (95% confidence interval 0.54–0.86) for the first reader and 0.83 (0.66–1.00) for the second reader. The Cohen’s kappa values for inter-rater reliability were 0.67 (0.50–0.85) and 0.65 (0.44–0.86) for the second reading respectively (p < 0.0001). Conclusion: The three tumour–mass interface characteristics investigated are all important characteristics of the claw sign. Intra- and inter-rater reliability is moderate to strong for all characteristics and overall impression of the claw sign. The claw sign is therefore sensitive in the accurate placement of an intra-renal mass but lacks specificity.
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    A silver bullet? The role of radiology information system data mining in defining gunshot injury trends at a South African tertiary-level hospital
    (2021-03) Creamer, Dale K.; Bagadia, Asif; Daniels, Clive; Pitcher, Richard D.
    Background: South Africa (SA) has no national injury surveillance system, and hence, nonfatal gunshot injuries are not routinely recorded. Most firearm-related injuries require multidetector computer tomography (MDCT) assessment at a tertiary-level facility. MDCT scanning for victims with gunshot injuries thus provide an indication of the societal burden of firearm trauma. The potential of the modern radiology information system (RIS) to serve as a robust research tool in such settings is not fully appreciated. Objective: The aim of this study was to evaluate the use of institutional RIS data in defining MDCT scanning trends for gunshot victims presenting to a tertiary-level SA hospital. Method: A single-institution, retrospective, comparative study was conducted at the Tygerberg Hospital (TBH) Trauma Unit for the years 2013 and 2018. Using data-mining software, customised RIS searches for information on all gunshot-related emergency computed tomography scans in the respective years were performed. Demographic, temporal, anatomical and scan-protocol trends were analysed by cross tabulation, Chi-squared and Fisher’s exact tests. Results: Gunshot-related emergency MDCT scans increased by 62% (546 vs. 887) from 2013 to 2018. Lower-limb CT angiography was the commonest investigation in both periods. A higher proportion of victims in 2018 sustained thoracic injuries (12.5% vs. 19.8%; p < 0.01) and required imaging of more than two body parts (13.1% vs. 19.2%; p < 0.01). Conclusion: By using RIS data to demonstrate the increasing gunshot-related MDCT workload in the review period, as well as a pattern of more complex and potentially life-threatening injury, this study highlights the burden of firearm trauma in the society and the potential role of the modern RIS as a robust research tool.
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    Mammography reporting at Tygerberg Hospital, Cape Town, South Africa
    (Health & Medical Publishing Group, 2014-07) Pitcher, Richard; Lotz, Jan; Ackermann, Christelle; Bagadia, Asif; Davis, Razaan; Du Plessis, Anne-Marie; Griffith-Richards, Stephanie; Hattingh, Retha; Wagener, Georg; Apffelstaedt, Justus; Dalmayer, Lisa; Baatjes, Karin
    In their recent article, Apffelstaedt et al.[1] analysed 16 105 mammograms performed at Tygerberg Hospital (TBH), Cape Town, South Africa (SA), between 2003 and 2012. The summary reported that ‘mammograms were read by experienced breast surgeons’, while the discussion stated: ‘A further noteworthy fact is that this TBH series was based exclusively on mammography interpretation by surgeons with a special interest in breast health.’ The suggestion that mammograms were exclusively interpreted by breast surgeons does not reflect the mammography workflow at our institution.
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    Towards equity : a retrospective analysis of public sector radiological resources and utilization patterns in the metropolitan and rural areas of the Western Cape Province of South Africa in 2017
    (BMC (part of Springer Nature), 2021) Van Zyl, Beulah C.; Barnard, Michelle Monique; Cloete, Keith; Fernandez, Amanda; Mukosi, Matodzi; Pitcher, Richard Denys
    Background: The reduction of inequality is a key United Nations 2030 Sustainable Development Goal (WHO, Human Resources for Health: foundation for Universal Health Coverage and the post-2015 development agenda, 2014; Transforming our world: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform, 2020). Despite marked disparities in radiological services globally, particularly between metropolitan and rural populations in low- and middle-income countries, there has been little work on imaging resources and utilization patterns in any setting (Transforming our world: the 2030 Agenda for Sustainable Development .:. Sustainable Development Knowledge Platform, 2020; WHO, Local Production and Technology Transfer to Increase Access to Medical Devices, 2019; European Society of Radiology (ESR), Insights Imaging 6:573-7, 2015; Maboreke et al., An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity, 2020; Kabongo et al., Pan Afr Med J 22, 2015; Skedgel et al., Med Decis Making 35:94-105, 2015; Mollura et al., J Am Coll Radiol 913-9, 2014; Culp et al., J Am Coll Radiol 12:475-80, 2015; Mbewe et al., An audit of licenced Zambian diagnostic imaging equipment and personnel, 2020). To achieve equity, a better understanding of the integral components of the so called “imaging enterprise” is important. The aim was to analyse a provincial radiological service in a middle-income country. Methods: An institutional review board-approved retrospective audit of radiological data for the public healthcare sector of the Western Cape Province of South Africa for 2017, utilizing provincial databases. We conducted population-based analyses of imaging equipment, personnel, and service utilization data for the whole province, the metropolitan and the rural areas. Results: Metropolitan population density exceeds rural by a factor of ninety (1682 vs 19 people/km²). Rural imaging facilities by population are double the metropolitan (20 vs 11/10⁶ people). Metropolitan imaging personnel by population (112 vs 53/10⁶ people) and equipment unit (1.7 vs 0.7/unit) are more than double the rural. Overall population-based utilization of imaging services was 30% higher in the metropole (289 vs 214 studies/10³ people), with mammography (24 vs 5 studies/10³ woman > 40 years) and CT (21 vs 6/10³ people) recording the highest, and plain radiography (203 vs 171/10³ people) the lowest differences. Conclusion: Despite attempts to achieve imaging equity through the provision of increased facilities/million people in the rural areas, differential utilization patterns persist. The achievement of equity must be seen as a process involving incremental improvements and iterative analyses ne progress towards the goal.