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Published in final edited form as: J Am Coll Radiol. 2012 Jul;9(7):488–494. doi: 10.1016/j.jacr.2012.01.005

White Paper Report of the 2011 RAD-AID Conference on International Radiology for Developing Countries: Integrating Multidisciplinary Strategies for Imaging Services in the Developing World

Kathryn L Everton 1,✉, Jonathan Mazal 2, Frank Lexa 3, Anna Starikovsky 4, Pablo Jimenez 5, Sanjay Jain 6, Kristen K DeStigter 7, Robert Nathan 8, Elizabeth Krebs 9, Vicki Noble 10, William Marks 11, Richard N Hirsh 12, Brad Short 13, Ryan Sydnor 14, Emily Timmreck-Jackson 15, Matthew P Lungren 16, Charles Maxfield 17, Ezana M Azene 18, Brian S Garra 19, Brian G Choi 20, Jonathan S Lewin 21, Daniel J Mollura 22
PMCID: PMC4844552  NIHMSID: NIHMS350348  PMID: 22748790

Abstract

The 2011 RAD-AID Conference on International Radiology for Developing Countries discussed data, experiences and models pertaining to radiology in the developing world, where widespread shortages of imaging services significantly reduce health care quality and increase health care disparity. This white paper from the 2011 RAD-AID Conference represents consensus advocacy of multidisciplinary strategies to improve planning, accessibility and quality of imaging services in the developing world. Conference presenters and participants discussed numerous solutions to imaging and healthcare disparities including: (1) economic development for radiology service planning, (2) public health mechanisms to address disease and prevention at the population and community levels, (3) comparative clinical models to implement various clinical and workflow strategies adapted to unique developing world community contexts, (4) education to improve training and optimize service quality, and (5) technology innovation to bring new technical capabilities to limited-resource regions.

Keywords: Radiology, developing countries, public health, residency education, international global imaging, economic development, radiology readiness, sustainability, technologists, radiology outreach, radiologic nursing

Introduction

Radiology services are scarce or nonexistent for most of the world's population. Recent reports from the World Health Organization (WHO) estimate that one-half to two-thirds of the world's population lacks access to medical imaging. Based on a recent global population census of approximately 7 billion people, this suggests a radiologic scarcity afflicting 3.5-4.7 billion individuals throughout the world. This disparity has widened over time due to a relative lack of progress in less developed regions (Figure 1)[1].

Figure 1.

Figure 1

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Trends in the annual frequency of diagnostic medical and dental radiological examinations per healthcare level. X-Axis: Health Care Level (HCL) I corresponds to more than 1,000 physicians per million population; HCL II, between 300 and 1,000; HCL III, between 100 and 300, and HCL IV, less than 100. This can also be interpreted as a range of country development with HCL I being highly industrialized countries and HCL IV being poorly developed countries[1]. Reproduced with permission from the World Health Organization.

With the widespread role of imaging in patient care for pulmonary disease, AIDS, maternal-infant health, tuberculosis (TB), cancer screening/management and trauma, this disparity of radiology access translates into a significant contributor to overall healthcare disparity[2-5]. In addition to disparate accessibility of radiology services, the WHO also identifies large gaps in image service quality and deficiencies in radiology service planning that exacerbate the radiology divide.

In this white paper, we describe and analyze multiple strategies for addressing the global radiology divide based on presentations at the 2011 RAD-AID Conference. Building upon the growing consensus and data summarized in prior RAD-AID Conference white papers [6, 7], we advocate for ongoing multidisciplinary strategies to arrive at innovative solutions for medical imaging including (1) economic development for financial sustainability in enterprise planning, (2) public health mechanisms to address treatment and prevention at the community level, (3) comparative clinical models to implement various clinical and workflow strategies adapted to unique developing world community contexts, (4) education to improve training and optimize service quality, and (5) technology innovation to bring new technical capabilities to limited-resource regions. The RAD-AID Conference advances this interdisciplinary agenda to address the complex task of improving radiology service.

Economic Development for Global Radiology

Radiology has a broad range of economic capital needs for implementation, from low-cost portable ultrasound to capital intensive cross-sectional modalities such as computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI), with diverse technologies in the middle of the economic spectrum such as radiography and mammography. Cost levels are further complicated by the range of data solutions such as analog printed film (still prevalent in the developing world) and digital data storage via picture archiving communications (PACS). Optimizing radiology solutions for a given community or facility is paramount to achieve the highest clinical yield. Given the range of economic scale involved in planning radiology for the developing world, the WHO has emphasized the need to improve radiology needs assessment and planning prior to implementing hardware, software and personnel: “Health care technologies are seen as peripheral to health care planners… The most important prerequisite… is that the potential recipient truly needs the… equipment and has the expertise and means to operate and maintain it.”[8]

To address the need for robust economic planning, partnerships between leading business schools and radiology service organizations have been initiated as a means to create comprehensive business plans for new radiology services. One example is the partnership between RAD-AID and the Columbia School of Business via Columbia's Pangea nonprofit assistance program [9]. Volunteer MBA students traveled with RAD-AID's radiology service team to India in January of 2011 to gather information and formulate a business plan that will provide mobile imaging and healthcare education to marginalized women in slums and rural regions. This program served as a follow-up to RAD-AID's Radiology-Readiness assessment performed in Northern India in 2010, which identified women's health as a pressing unmet need [10].

The Wharton School of Business Global Consulting Practicum (GCP) is another example of the integration of health and business professionals, offering a wide range of strategies to a variety of businesses and industries. As a model for nonprofit healthcare service advancement, Wharton GCP assisted Hope Village, a South African nongovernmental organization (NGO), to optimize efforts on behalf of orphans affected by AIDS, thus improving the NGO's economic development and social impact[11].

Partnering radiology nonprofit outreach with academic business programs yields several key benefits to both the business and radiology professional communities: (i) improves the strategic planning process for long term economic sustainability, (ii) educates the business community about the vital role of imaging technologies in healthcare systems, (iii) educates radiology healthcare personnel on business practices and economic analytical tools, and (iv) generates cross-pollination of economic and healthcare ideas for innovation. Based on initial pilots of RAD-AID's partnerships with business schools, the aim is to deepen, replicate, and expand these collaborations with other academic business institutions for more robust business plan development in the future.

Radiology and Public Health for the Developing World

In contrast to care at the doctor-patient level, public health addresses the role of radiology at the community level to guide public policy and address epidemiological challenges[12]. This is a key element of radiology in developing countries because radiology service planning for underserved populations necessitates an in-depth understanding of a population's culture, disease patterns, and healthcare system. TB is one example of radiologic scarcity broadly impacting public health efforts in the developing world, with 9.2 million new cases, 1.5 million deaths and 10 million children orphaned by parental TB deaths annually[13]. TB disease can be difficult to diagnose definitively. This is often due to the unavailability of bacterial cultures. Even when culture facilities are available, results are not available for at least 4-6 weeks due to the slow growth of Mycobacterium tuberculosis, which causes TB[3, 14]. In addition, since young children cannot produce sputa and have a higher incidence of extra-pulmonary disease, sensitivity of cultures and new automated nucleic acid amplification methods is extremely low (<20%)[15-18]. Therefore, chest radiographs are regarded as a key component of diagnosis and treatment monitoring, particularly among pediatric and HIV-infected patients. As most TB cases are now in the developing world, the inadequate quality and scarcity of chest imaging significantly limits global public health efforts to control the disease[19]. As advanced imaging is developed and validated to better diagnose and monitor TB, scalability of imaging will become an important component of disease control[20, 21].

Women's health is another significant public health issue impacted by the radiology divide. Examples include osteoporosis, diagnosed by bone densitometry, and breast cancer, detectable by mammography and ultrasound [22, 23]. Osteoporosis affects 200 million women world-wide and is a particularly widespread challenge in India, affecting 1 in 3 women [24]. RAD-AID has engaged public health and medical institutions in Northern India to implement a mobile women's health outreach program. The mobile unit will offer screening for breast cancer, cervical cancer and osteoporosis as well as targeted health education. The partnership will aid data collection on women's health, including barriers to engaging the health care system, obstacles to referrals, as well as patterns and rates of disease. This joint project aims to develop policies that will better incorporate radiologic services into public health programs [25].

To improve the interconnection between global radiology and public health, RAD-AID has also initiated a partnership with the WHO. Initial efforts in Latin America are planned through the WHO's Regional Office for the Americas, the Pan American Health Organization (PAHO). This pilot first aims to implement RAD-AID's Radiology-Readiness tool for participating Latin American and Caribbean hospitals through coordination with Ministries of Health (MOH), thus matching public health issues with optimized radiology solutions.

The radiology divide is also significantly impacted by human resource disparities. The developing world has a scarcity of radiologists and medical imaging technologists. According to Dr. Pablo Jimenez, Regional Advisor in Radiological Health for PAHO/WHO, “general practitioners often have to make [imaging] interpretations and unqualified staff [are] performing x-ray exposures.” Poor educational curricula, insufficient radiology educators, and ill-defined credentialing tracks exacerbate this human resource deficiency.

Education: Emphasizing Multidisciplinary Training

Educational resources are a vital element of international radiology service implementation and sustainability because of the advanced skills required for image acquisition and interpretation. The need for improved educational strategies is twofold: (1) educating personnel living in developed countries to serve in limited resource regions, and (2) educating local healthcare providers living in the developing world to improve the quality of radiologic service [26].

Educating the U.S. radiology community focuses on radiology residencies and academic medical centers as well as continuing medical education (CME) credits necessary for maintaining board certification. Although other medical and surgical specialties have incorporated international training into residency curricula, diagnostic radiology has yet to officially adopt international service into program requirements [6, 27-29]. Although there is a strong desire among radiology residents to participate in global service (as reflected by RAD-AID's published survey data[30]) and a steadily growing demand for the American College of Radiology (ACR) Goldberg-Reeder resident travel grant, the supply of interested residents greatly exceeds the opportunities for international radiology experience. The RAD-AID Conference consensus advocates structured supervised learning experiences for radiology residents with clearly defined educational milestones and work deliverables. Recent revision of the residency curriculum to accommodate new timing of the American Board of Radiology (ABR) certification exam may avail opportunities to incorporate international training. Ongoing efforts must address concerns about (1) liability and insurance coverage of traveling residents, (2) mechanisms for effective supervision and teaching of residents while abroad, and (3) workflow and salary coverage for residents on leave for international rotations.

The radiology enterprise consists of a variety of skilled stakeholders with diverse expertise, including radiologists, radiologic technologists, radiology nurses, medical physicists, engineers, administrators and information technology (IT) specialists. Local healthcare personnel in low-income regions require training and educational materials developed through input from complementary professions. Consequently, the RAD-AID Conference consensus advocates educational teams that blend specialized perspectives to create balanced strategies. Multidisciplinary teams have already been successfully implemented to improve efforts in CT dose reduction [31]. Given the importance of local healthcare personnel, translation of educational materials into culturally appropriate contexts and languages is also paramount. An example of this objective is RAD-AID's translation effort with WHO/PAHO of Radiology-Readiness for future assessments in Haiti and Latin America.

RAD-AID's new partnerships with the Association for Radiologic and Imaging Nursing (ARIN) and the American Society of Radiologic Technologists (ASRT) reflect the goal of skill-set integration and complement longstanding partnerships with the ACR, the Radiological Society of North America (RSNA) and Engineering World Health (EWH)[32]. Historically, each specialized knowledge source offered international training independently, but recent trends favor interdisciplinary educational efforts. One manifestation of this trend is the RAD-AID Conference provision of continuing education (CE) credits (via the ASRT partnership) to technologists attending the annual meeting. CE credits to other constituencies may be provided for future conferences.

RAD-AID's 2010 Radiology-Readiness Initiative in China, a collaboration between Project HOPE and RAD-AID, identified a great need for radiology education. This project began in 2011 with RAD-AID's support of radiologists presenting at the Chinese Society of Radiologists (CSR) annual meetings. This model has expanded to include more subspecialty meetings of the CSR and grand rounds presentations at leading urban hospitals, as well as efforts to improve and standardize certification of radiology professionals throughout China. RAD-AID's China Initiative has been published in the Journal of the Chinese Radiology, which include publication of US standards of radiology training for potential broader adoption in China [33]. Given that two-thirds of the world's poorest individuals (earning less than $1.25 USD per day) live in middle-income countries such as India and China, this radiology outreach initiative aims to address healthcare disparities affecting a large population.

Clinical Models

The heterogeneity of cultural, geographic, economic and healthcare contexts throughout the developing world necessitates the design and testing of multiple strategies for new imaging services. A successful radiology strategy in region may or may not be adaptable to another community, country or region. Therefore, the RAD-AID conference encourages dialog to evaluate ideas from multiple perspectives and to incorporate differences in experience among international service volunteers.

Given ultrasound's high utility, versatility and low cost, multiple models of ultrasound-based service have been implemented to assist developing countries [34]. One model provides direct on-site instruction in goal directed, point of care ultrasound to physicians. The Physicians Ultrasound in Rwanda Education initiative (PURE), administered by emergency medicine physicians, has partnered with the Rwandan Government to design educational programs that fit the needs of their healthcare system. A second model trains midwives for obstetric screening at the point of care, implemented by the University of Washington in Uganda. A third model provides direct instruction to sonographers. For example, a sonography curriculum leading to ARDMS certification in Ghana was presented at the 2009 RAD-AID Conference by Ann Polin. A fourth model provides direct on-site instruction to nonphysicians in sonographic technique and interpretation, as presented by William Marks from pilot projects in Mali. A fifth model, initiated by Imaging the World (ITW) in Uganda, trains personnel with little or no prior medical experience to perform regimented ultrasound protocol sweeps based on physical landmarks with image transmission to a central facility for interpretation (Figure 2). Finally, off-site instruction to healthcare providers visiting the United States is exemplified by Jefferson University Research and Education Institute in the Teaching the Teachers program, as led and presented by Barry Goldberg in the 2009 and 2010 RAD-AID Conferences[35].

Figure 2.

Figure 2

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Imaging the World (ITW) data flow model for ultrasound (US) services in rural limited resource regions showing transmission of DICOM images from scanner to laptop and PACS to generate report via short message service (SMS) to local clinic.

There are key similarities among these models that warrant attention and reflect radiology's progress in the developing world. First, these models place high importance on connected referral systems to further link care providers using ultrasound as a vital data point for triage. Second, these models emphasize peer education as a resource for replicating and transmitting knowledge among local personnel [36]. Third, these models often place clinical priority on maternal-infant health, with fetal ultrasound as a screening measure that may improve management of obstetric deliveries [37]. This emphasis highlights radiology's role in the global public health issue of maternal-infant mortality. Fourth, these models all emphasize the participation and collaboration among diverse stakeholders for executing these objectives.

Breast imaging models presented at the RAD-AID Conference also illustrate the range of approaches that can be implemented in the developing world. Direct on-site multidisciplinary instruction in stationary mammography facilities is advocated by Richard Hirsh, M.D. of Radiology Mammography International (RMI), with project evidence from Asia and Latin America. RAD-AID's initiative in Northern India utilizes mobile imaging linked with tertiary care center referral services to serve marginalized populations. Combining screening interventions and targeted health education can potentially improve healthcare for women living in slums and rural regions in a cost-effective manner [38].

Although numerous other models and projects are underway throughout the world, the examples presented at the 2011 RAD-AID Conference provide solutions to personnel shortages and educational challenges which remain major barriers to international radiology service. These solutions will be further discussed, refined and optimized in the future.

Technology Innovation

The role of technology innovation is paramount in radiology's international outreach as novel technologies can improve quality, optimize connectivity and decrease cost of services. Examples of technology innovation include imaging services and educational platforms used to support personnel. The continuing proliferation of 3G cell networks, broadband internet and WIFI present new opportunities for digitally connecting radiology facilities in the developing world. ITW, for example, advocates a unique image-compression technique to facilitate ultrasound transmission to remote diagnostic centers. Moreover, RAD-AID advocates cloud-based PACS solutions for low cost image storage that can also facilitate inter-institutional consultations, educational case-rounds and direct radiology service.

The proliferation of smart phone technologies allows for new opportunities in imaging. Brian Choi, M.D. (George Washington University) presented a model for smartphone-based echocardiography at the 2011 RAD-AID Conference. More than 80% of cardiovascular death occurs in low- and middle-income countries, where echocardiography is scarce and could be life-saving [39-41]. The pilot was performed in Honduras and tested transmission of echocardiograms via SSL 128 bit pipeline to iPhone or iPod devices using the mVisum application, which demonstrated 90% interpretation concordance relative to workstation-based interpretation [42].

Technology-based solutions for training and education are also an important source of radiology outreach for limited-resource regions. This observation has been reported by the WHO and RAD-AID's Radiology-Readiness assessments. Education and training of technologists is a particular area of need, and has underpinned recent partnership efforts between RAD-AID, the ASRT, and the ACR. RAD-AID presented collaborative efforts to implement an online learning management system (LMS) for technologists, radiologists and nurses in the developing world. The World Radiography Educational Trust Fund (WRETF) presented an ASRT-funded project that embedded PDFs, interactive point-of-care applications, and electronic textbooks onto mobile electronic devices (MEDs). The MEDs provide internet-based solutions and digitized texts for technologists who would not otherwise have access to these vital references. RAD-AID is also in the early stages of advising the PAHO/WHO Virtual Campus program on using radiologic resources for educating public health personnel in the developing world [1].

Conclusions

This white paper of the 2011 RAD-AID Conference presents a consensus perspective on multidisciplinary approaches to sustainable radiology in the developing world by integrating economic development, public health programming, clinical model testing, educational strategies and technology innovation. Key themes of the conference include:

  • Partnerships among radiology nonprofit organizations and academic business institutions can improve international health service planning via integrated teams of health care and business professionals.

  • Clinical model implementation, such as ultrasound and breast imaging, can be tailored to the specific needs of communities with limited resources to optimize infrastructure and integrate these models to existing referral and treatment systems.

  • Links between public health programs and radiology service organizations, such as the collaborations between WHO and RAD-AID, potentiate the contribution of high-quality medical imaging to global health issues such as cancer screening, maternal-infant health, osteoporosis, women's health, TB, and AIDs related disease.

  • Education of personnel in the developed world and dissemination of training to developing countries continues to be a key objective of international radiology service efforts through internet-based and on-site mechanisms.

  • Technology innovations continue to improve connectivity through 3G cellular phone networks, advanced digital PACS, smartphone-based image interpretation, and learning management systems to strengthen radiology capacity in developing countries.

Acknowledgments

The 2011 RAD-AID Conference on International Radiology for Developing Countries was funded in part by the Gatewood Foundation (Baltimore, MD), hosted by the Russell H. Morgan Department of Radiology at Johns Hopkins Hospital in Baltimore, Maryland, and received general program support from the staff and volunteers at RAD-AID International (http://www.rad-aid.org.)

Footnotes

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Contributor Information

Kathryn L. Everton, Email: keverton@rad-aid.org, Duke University, Department of Radiology, RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

Jonathan Mazal, Email: jmazal@rad-aid.org, US Trustee, World Radiography Educational Trust Fund (WRETF), RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

Frank Lexa, Email: frank22@wharton.upenn.edu, Drexel University College of Medicine, Global Consulting Practicum & Adjunct Professor of Marketing, The Wharton School of Business, University of Pennsylvania.

Anna Starikovsky, Email: anna.starikovsky@gmail.com, RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

Pablo Jimenez, Email: jimenezp@paho.org, Pan American Health Organization (PAHO), Regional Office of the World Health Organization (WHO).

Sanjay Jain, Email: sjain5@jhmi.edu, Johns Hopkins University School of Medicine and Bloomberg School of Public Health.

Kristen K. DeStigter, Email: Kristen.DeStigter@vtmednet.org, Fletcher Allen Health Care/University of Vermont, Co-Founder, Imaging the World.

Robert Nathan, Email: ronathan@u.washington.edu, Department of Radiology, Harborview Medical Center, University of Washington.

Elizabeth Krebs, Email: liz@ultrasound-rwanda.org, Physicians Ultrasound in Rwanda Education (PURE).

Vicki Noble, Email: vnoble@partners.org, Massachussets General Hospital, Department of Emergency Medicine.

William Marks, Email: wmarks@radiax.com, Radia Medical Imaging, Seattle, Washington.

Richard N. Hirsh, Email: debhirsh@juno.com, Radiology Mammography International (RMI).

Brad Short, Email: bshort@acr-arrs.org, American College of Radiology.

Ryan Sydnor, Email: rsydnor@rad-aid.org, Duke University, Department of Radiology, RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

Emily Timmreck-Jackson, Email: emilytimmreck@gmail.com, Association for Radiologic Imaging Nursing (ARIN), 7794 Grow Drive, Pensacola, FL 32514.

Matthew P. Lungren, Email: mlungren@rad-aid.org, Duke University, Department of Radiology, RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

Charles Maxfield, Email: charles.maxfield@duke.edu, Duke University, Department of Radiology, Duke Radiology Residency, RAD-AID International, Adjunct Faculty.

Ezana M. Azene, Email: eazene@gmail.com, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Umiversity School of Medicine, RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

Brian S. Garra, Email: brian.garra@fda.hhs.gov, Imaging the World.

Brian G. Choi, Email: bchoi@gwu.edu, The Richard B. & Lynne V. Cheney Cardiovascular Institute, George Washington University.

Jonathan S. Lewin, Email: jlewin2@jhmi.edu, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Radiologist-in-Chief, The Johns Hopkins Hospital.

Daniel J. Mollura, Email: dmollura@rad-aid.org, RAD-AID International, 2620 Spencer Road, Chevy Chase, MD 20815.

References

  • 1.Sources and effects of ionizing radiation UNSCEAR 2008 Report. 2008;I [Google Scholar]
  • 2.Levine AC, Presser DZ, Rosborough S, Ghebreyesus TA, Davis MA. Understanding barriers to emergency care in low-income countries: view from the front line. Prehosp Disaster Med. 2007 Sep-Oct;22(5):467–70. doi: 10.1017/s1049023x00005240. [DOI] [PubMed] [Google Scholar]
  • 3.Siddiqi K, Lambert ML, Walley J. Clinical diagnosis of smear-negative pulmonary tuberculosis in low-income countries: the current evidence. Lancet Infect Dis. 2003 May;3(5):288–96. doi: 10.1016/s1473-3099(03)00609-1. [DOI] [PubMed] [Google Scholar]
  • 4.Rees D, Murray J. Silica, silicosis and tuberculosis. Int J Tuberc Lung Dis. 2007 May;11(5):474–84. [PubMed] [Google Scholar]
  • 5.Sankaranarayanan R, Boffetta P. Research on cancer prevention, detection and management in low- and medium-income countries. Ann Oncol. 2010 Oct;21(10):1935–43. doi: 10.1093/annonc/mdq049. [DOI] [PubMed] [Google Scholar]
  • 6.Welling RD, Azene EM, Kalia V, Pongpirul K, Starikovsky A, Sydnor R, et al. White Paper Report of the 2010 RAD-AID Conference on International Radiology for Developing Countries: identifying sustainable strategies for imaging services in the developing world. J Am Coll Radiol. 2011 Aug;8(8):556–62. doi: 10.1016/j.jacr.2011.01.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Mollura DJ, Azene EM, Starikovsky A, Thelwell A, Iosifescu S, Kimble C, et al. White Paper Report of the RAD-AID Conference on International Radiology for Developing Countries: identifying challenges, opportunities, and strategies for imaging services in the developing world. J Am Coll Radiol. 2010 Jul;7(7):495–500. doi: 10.1016/j.jacr.2010.01.018. [DOI] [PubMed] [Google Scholar]
  • 8.Berra K, Fletcher BJ, Hayman LL, Miller NH. Global cardiovascular disease prevention: a call to action for nursing: the global burden of cardiovascular disease. Eur J Cardiovasc Nurs. 2011 Jul;10(2):S1–2. doi: 10.1016/S1474-5151(11)00107-1. Introduction. [DOI] [PubMed] [Google Scholar]
  • 9.Dorovini-Zis K, Prameya R, Bowman PD. Culture and characterization of microvascular endothelial cells derived from human brain. Lab Invest. 1991;64(3):425–36. [PubMed] [Google Scholar]
  • 10.Greenemeier L. PET Project: Radiologists push imaging technologies in developing countries. Scientific American; 2010. [Accessed November 24, 2011]. Available at http://wwwscientificamericancom/articlecfm?id=radiology-developing-countries. [Google Scholar]
  • 11.Wharton School of Business. [Accessed November 12, 2011];GCP Team helps to advance economic development efforts of Mosaic (previously Hope Village), South Africa-Based NGO, 4/26/2010. Available at http://mktgweb.wharton.upenn.edu/gcpcourse/
  • 12.Hillman BJ. Radiology and public health. J Am Coll Radiol. 2008 Mar;5(3):155. doi: 10.1016/j.jacr.2007.12.005. [DOI] [PubMed] [Google Scholar]
  • 13.Tsenova L, Sokol K, Freedman VH, Kaplan G. A combination of thalidomide plus antibiotics protects rabbits from mycobacterial meningitis-associated death. J Infect Dis. 1998 Jun;177(6):1563–72. doi: 10.1086/515327. [DOI] [PubMed] [Google Scholar]
  • 14.Harries AD, Banda HT, Boeree MJ, Welby S, Wirima JJ, Subramanyam VR, et al. Management of pulmonary tuberculosis suspects with negative sputum smears and normal or minimally abnormal chest radiographs in resource-poor settings. Int J Tuberc Lung Dis. 1998 Dec;2(12):999–1004. [PubMed] [Google Scholar]
  • 15.Nelson LJ, Wells CD. Global epidemiology of childhood tuberculosis. Int J Tuberc Lung Dis. 2004 May;8(5):636–47. [PubMed] [Google Scholar]
  • 16.Getahun H, Harrington M, O'Brien R, Nunn P. Diagnosis of smear-negative pulmonary tuberculosis in people with HIV infection or AIDS in resource-constrained settings: informing urgent policy changes. Lancet. 2007 Jun 16;369(9578):2042–9. doi: 10.1016/S0140-6736(07)60284-0. [DOI] [PubMed] [Google Scholar]
  • 17.Enarson PM, Enarson DA, Gie R. Management of tuberculosis in children in low-income countries. Int J Tuberc Lung Dis. 2005 Dec;9(12):1299–304. [PubMed] [Google Scholar]
  • 18.Nicol MP, Workman L, Isaacs W, Munro J, Black F, Eley B, et al. Accuracy of the Xpert MTB/RIF test for the diagnosis of pulmonary tuberculosis in children admitted to hospital in Cape Town, South Africa: a descriptive study. Lancet Infect Dis. 2011 Nov;11(11):819–24. doi: 10.1016/S1473-3099(11)70167-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Mathers C, Fat DM, Boerma JT World Health Organization. The global burden of disease : 2004 update. Geneva, Switzerland: World Health Organization; 2008. [Google Scholar]
  • 20.Davis SL, Nuermberger EL, Um PK, Vidal C, Jedynak B, Pomper MG, et al. Noninvasive pulmonary [18F]-2-fluoro-deoxy-D-glucose positron emission tomography correlates with bactericidal activity of tuberculosis drug treatment. Antimicrob Agents Chemother. 2009 Nov;53(11):4879–84. doi: 10.1128/AAC.00789-09. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Sathekge M, Maes A, Kgomo M, Stoltz A, Van de Wiele C. Use of 18F-FDG PET to predict response to first-line tuberculostatics in HIV-associated tuberculosis. J Nucl Med. 2011 Jun;52(6):880–5. doi: 10.2967/jnumed.110.083709. [DOI] [PubMed] [Google Scholar]
  • 22.Cazap E, Distelhorst SR, Anderson BO. Implementation science and breast cancer control: a Breast Health Global Initiative (BHGI) perspective from the 2010 Global Summit. Breast. 2011 Apr;20(2):S1–2. doi: 10.1016/j.breast.2011.02.013. [DOI] [PubMed] [Google Scholar]
  • 23.Anderson BO, Cazap E, El Saghir NS, Yip CH, Khaled HM, Otero IV, et al. Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus, 2010. Lancet Oncol. 2011 Apr;12(4):387–98. doi: 10.1016/S1470-2045(11)70031-6. [DOI] [PubMed] [Google Scholar]
  • 24.International Osteoporosis Foundation. [Accessed November 13, 2011];Facts and statistics about osteoporosis and its impact. Available at http://www.iofbonehealth.org/facts-and-statistics.html.
  • 25.Mittra I. Breast cancer screening in developing countries. Prev Med. 2011 Sep 1;53(3):121–2. doi: 10.1016/j.ypmed.2011.06.010. [DOI] [PubMed] [Google Scholar]
  • 26.Rabinowitz DA, Pretorius ES. Postgraduate radiology training in sub-Saharan Africa: a review of current educational resources. Acad Radiol. 2005 Feb;12(2):224–31. doi: 10.1016/j.acra.2004.11.014. [DOI] [PubMed] [Google Scholar]
  • 27.Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med. 2002 Jul;9(7):679–83. doi: 10.1111/j.1553-2712.2002.tb02145.x. [DOI] [PubMed] [Google Scholar]
  • 28.Torjesen K, Mandalakas A, Kahn R, Duncan B. International child health electives for pediatric residents. Arch Pediatr Adolesc Med. 1999 Dec;153(12):1297–302. doi: 10.1001/archpedi.153.12.1297. [DOI] [PubMed] [Google Scholar]
  • 29.Schultz SH, Rousseau S. International health training in family practice residency programs. Fam Med. 1998 Jan;30(1):29–33. [PubMed] [Google Scholar]
  • 30.Lungren MP, Horvath JJ, Welling RD, Azene EM, Starikovsky A, Bashir MR, et al. Global health training in radiology residency programs. Acad Radiol. 2011 Jun;18(6):782–91. doi: 10.1016/j.acra.2011.02.009. [DOI] [PubMed] [Google Scholar]
  • 31.Goske MJ, Applegate KE, Boylan J, Butler PF, Callahan MJ, Coley BD, et al. The ‘Image Gently’ campaign: increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol. 2008 Mar;38(3):265–9. doi: 10.1007/s00247-007-0743-3. [DOI] [PubMed] [Google Scholar]
  • 32.Malkin RA. Design of health care technologies for the developing world. Annu Rev Biomed Eng. 2007;9:567–87. doi: 10.1146/annurev.bioeng.9.060906.151913. [DOI] [PubMed] [Google Scholar]
  • 33.Maxfield C, Grimm L, Chen J. Graduate radiology training in the United States. Chinese Journal of Radiology. 2011;45(11) [Google Scholar]
  • 34.Mindel S. Role of imager in developing world. Lancet. 1997 Aug 9;350(9075):426–9. doi: 10.1016/S0140-6736(97)03340-0. [DOI] [PubMed] [Google Scholar]
  • 35.Baltarowich OH, Goldberg BB, Wilkes AN, Anane-Firempong A, Veloski JJ. Effectiveness of “teaching the teachers” initiative for ultrasound training in Africa. Acad Radiol. 2009 Jun;16(6):758–62. doi: 10.1016/j.acra.2008.12.023. [DOI] [PubMed] [Google Scholar]
  • 36.Shah S, Noble VE, Umulisa I, Dushimiyimana JM, Bukhman G, Mukherjee J, et al. Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda. Int J Emerg Med. 2008 Sep;1(3):193–6. doi: 10.1007/s12245-008-0053-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Hofmeyr GJ. Routine ultrasound examination in early pregnancy: is it worthwhile in low-income countries? Ultrasound Obstet Gynecol. 2009 Oct;34(4):367–70. doi: 10.1002/uog.7352. [DOI] [PubMed] [Google Scholar]
  • 38.Kim JJ, Salomon JA, Weinstein MC, Goldie SJ. Packaging health services when resources are limited: the example of a cervical cancer screening visit. PLoS Med. 2006 Nov;3(11):e434. doi: 10.1371/journal.pmed.0030434. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Kishore SP, Vedanthan R, Fuster V. Promoting global cardiovascular health ensuring access to essential cardiovascular medicines in low- and middle-income countries. J Am Coll Cardiol. 2011 May 17;57(20):1980–7. doi: 10.1016/j.jacc.2010.12.029. [DOI] [PubMed] [Google Scholar]
  • 40.Fuster V, Kelly BB, Vedanthan R. Global cardiovascular health: urgent need for an intersectoral approach. J Am Coll Cardiol. 2011 Sep 13;58(12):1208–10. doi: 10.1016/j.jacc.2011.05.038. [DOI] [PubMed] [Google Scholar]
  • 41.Kobal SL, Lee SS, Willner R, Aguilar Vargas FE, Luo H, Watanabe C, et al. Hand-carried cardiac ultrasound enhances healthcare delivery in developing countries. Am J Cardiol. 2004 Aug 15;94(4):539–41. doi: 10.1016/j.amjcard.2004.04.077. [DOI] [PubMed] [Google Scholar]
  • 42.Choi BG, Mukherjee M, Dala P, Young HA, Tracy CM, Katz RJ, et al. Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation. J Am Soc Echocardiogr. 2011 Dec;24(12):1325–30. doi: 10.1016/j.echo.2011.08.007. [DOI] [PubMed] [Google Scholar]

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