Dec 03-04: Pathology at Mulago Hospital

Tuesday, December 03 2024

After a long day of travel, our destination for the first week is Kampala. We began our day at Mulago Hospital, where we had the opportunity to meet Dr. Kalungi, one of our primary partners. Our day kicked off with an insightful conversation about his work and how the Pathology Department is organized.

We were then introduced to Boaz, a cytotechnologist who had already worked with the previous Ekyaalo team. Boaz gave us a comprehensive tour of the Pathology Department, highlighting key areas like the recently acquired whole slide scanner, microscope rooms, and the space where Fine Needle Aspiration (FNA) biopsies are performed. He also explained how patients are referred from more local healthcare levels to Mulago.

DiffQuik staining

After the tour, the team gathered to prepare materials for our studies. We classified and imaged several de-identified patient slides using the Ekyaalo Diagnostics camera — an exciting milestone, as this was our first time accessing Ugandan slides under the microscope.

Once the materials were ready, we had the opportunity to interview four pathologists at the Uganda Cancer Institute (UCI). This allowed us to listen to their discussion and gather feedback on the information they need for diagnosis. This session also served as an opportunity for our team to refine our study protocol and assess how our materials performed in a real-world setting, ensuring our upcoming studies will go even more smoothly.

After a productive day, we had a late lunch with Darius at the Hospital Guest House. Darius is our partner at the School of Public Health at Makerere University and has been an instrumental guide and connection throughout this trip. We are deeply grateful for his help, and the interesting conversations we have shared!

Darius and Boaz showing us around the hospital

Our first taste of local food was delicious, and we absolutely loved matoke, g-nut, and posho. Later, we headed to Acacia Mall to meet Dan! He has been a cornerstone of Ekyaalo Diagnostics’ progress over the past two years, and his valuable insights and guidance based on his extensive experience with Ekyaalo have been crucial for us. We are very happy to have met him in person!

First dinner with Dan

Wednesday, December 04 2024

The next day we woke up early ready for a new set of interviews at Mulago Hospital. In the morning, we could meet with Dr. Kalungi and another senior pathologists. In this new set of interviews, we put special attention in asking about the interaction with AI, and we learned about potential liability risks, and the requirements to validate a diagnosis in Uganda.

At the same time, we met a resident who gave us a very different perspective about the needs of the younger pathologists. Cytology is a nuanced and subjective field, so it is key for us to learn from all the different experiences. We also talked to Boaz again to learn about the Hub system, which is the network for cytology and histology slide transportation in Uganda.

After lunch, we had a very interesting conversation with an innovative pathologist very aligned with our vision for Ekyaalo. He taught us a lot about cell characteristics, and how the network and sharing between clinicians at different healthcare centers works. His positive experience empowers us to believe our project will be highly impactful!

To finish the day, we enjoyed traditional Ugandan dances at the Ndere Cultural Centre. The performance was a beautiful display of dances and traditions from various regions. We are truly grateful for the opportunity to immerse ourselves in the culture and history of this country, and we look forward to learning even more as we continue to spend time with all the people we meet.

Dancing while balancing piles of eight items on their heads.

Our Main Takeaways to drive future design changes:

• Symptomatic patients are referred to Mulago for FNAC. If the results are benign, the mass is typically removed in an outpatient procedure. If the results are suspicious or malignant, the patient is referred to UCI for Core Needle Biopsy (CNB). Then, chemotherapy is administered, followed by resection.

• Hub transportation of breast cancer slides is uncommon. The vast majority of cases at district areas are referred for walks-in at Mulago.

• Two pathologists are required to validate a diagnosis, even when AI is involved.

• Adequacy of slides is not based on the number of clusters, but on the presence of visible cells and proper staining.

• Cytology images must be paired with the patient’s history, imaging, and clinical examination. Key parameters include age, pain level, and previous pregnancies.

• Multiple magnifications are necessary for diagnosis. Typically, a low magnification (4x or 10x) for cell pattern and cellularity, and a high one (40x) for nuclear examination.

• Our cluster detection needs refinement to only detect epithelial cell groups, not any cluster-looking area. In addition, presence of single cells and slide background are key.

• Classification types are Suspicious, Benign and Malignant.

The first two days were filled with meaningful work and key learning experiences for our team. We had the opportunity to meet the people who have supported us from afar, and we are truly grateful for their time and insights. This marks the beginning of what promises to be an even more rewarding journey ahead!

Tulabagane enkya!

(See you tomorrow!)