Stephen J. Beningfield

A simple telemedicine system using a digital camera

Radiographs on a viewing box were photographed at a remote hospital in South Africa using a digital camera with a resolution of 1024x768 pixels at 24-bit colour depth. The resultant images were stored in JPEG format and transmitted as email attachments to be read on a PC monitor by radiologists in Durban and Cape Town. Twenty-seven images were received, of which 23 were of diagnostic quality (85%). The mean file size was 120 kByte. For quality control purposes, 100 chest radiographs were photographed at a base hospital and read by a radiologist blinded to the diagnosis. In this study 96 images were of diagnostic quality (96%) and the correct diagnosis was made in 90 cases (94%). Incorrect readings were made in six cases (6%): small pulmonary nodules (less than 1 cm in diameter) were missed in five cases and in one case early apical tuberculosis was missed. Digital camera technology permits simple, inexpensive telemedicine. Limited spatial resolution is a concern when reading chest images with small pulmonary nodules and infiltrates.

Haemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolisation

Although traumatic haemobilia is uncommon and occurs in less than 3% of liver injuries, the magnitude of the bleeding may result in life-threatening complications. This study evaluated the efficacy of selective hepatic artery embolisation (HAE) in the control of bleeding in patients with traumatic haemobilia. The demographic, clinical and angiographic data on all patients with traumatic haemobilia were obtained from a prospectively documented database of patients undergoing visceral angiography for liver haemorrhage between 1967 and 2002. During the 36-year period under review, 30 patients were found to have haemobilia on selective hepatic angiography. Ten of these 30 patients had haemobilia due to accidental non-iatrogenic trauma and form the basis of this study. In 8 of the 10 patients haemobilia resulted from penetrating liver injuries and two patients had blunt trauma. The mean delay between the initial injury and the diagnosis of haemobilia was 23.5 (range 1-120) days. The mean blood loss before angiography was 8 (range 3-19) units. Six patients were treated successfully with selective hepatic arterial embolisation, three required surgery and one resolved without any intervention. There were no deaths and no complications resulting in long term sequelae. Traumatic haemobilia is an uncommon but life-threatening complication of liver injury. Selective arterial embolisation is the initial treatment of choice with a substantial rate of success and a low incidence of serious complications.

Successful treatment of infected thoracoabdominal aortic graft by percutaneous catheter drainage

A large perigraft abscess infected with Klebsiella sp. developed around a woven Dacron prosthesis inserted into a patient at high-risk with a leaking thoracoabdominal aortic aneurysm. Percutaneous insertion of a sump drainage catheter under ultrasound guidance accompanied by local and systemic antibiotic therapy was the only reasonable management option. Two years later the patient remains well with no evidence of sepsis on clinical examination, hematologic studies, computerized tomography or indium 111 labeled autologous leucocyte imaging. This technique may be successful in selected high-risk situations.

Abdominal and pericardial ultrasound in suspected extrapulmonary or disseminated tuberculosis

OBJECTIVE Tuberculosis (TB) in patients with or without advanced HIV infection may present as smear-negative, extrapulmonary and/or disseminated forms. We studied the role of pericardial and abdominal ultrasound examinations in the determination of extrapulmonary or disseminated TB. METHODS A prospective descriptive and analytic cross-sectional study design was used to determine the ultrasound findings of value in patients with subsequently proven TB. Ultrasound examinations were performed on 300 patients admitted to G F Jooste Hospital with suspected extrapulmonary or disseminated TB. OUTCOME MEASURES The presence of hepatomegaly, splenomegaly, lymphadenopathy (location, size and appearance), ascites, pleural effusions, pericardial effusions and/or splenic micro-abscesses was noted. Clinical findings, microbiological and serological data were also recorded, correlated and analysed. RESULTS Complete data sets were available for 267 patients; 91.0% were HIV positive, and 70.0% had World Health Organization clinical stage 4 disease. Active TB (determined by smear or culture) was present in 170 cases (63.7%). Ultrasonically visible abdominal lymphadenopathy over 1 cm in minimum diameter correlated with active TB in 55.3% of cases (odds ratio (OR) 2.6, 95% confidence interval (CI) 1.5 - 4.6, p = 0.0002). Ultrasonographically detected pericardial effusions (OR 2.8, 95% CI 1.6 - 5.0, p < 0.0001), ascites (OR 2.2, 95% CI 1.2 - 4.2, p = 0.005) and splenic lesions (OR 1.9, 95% CI 1.0 - 3.5, p = 0.024) also predicted active TB. CONCLUSION Pericardial and abdominal ultrasound examinations are valuable supplementary investigations in the diagnosis of suspected extrapulmonary or disseminated TB.

Selective hepatic artery embolization in complex liver injury

The value of Hounsfield unit (HU) assigned to a particular Requests for reprints should be addressed to: Mr G. J. Oettlb, area is a mean value for the tissue contained in the volume of Department of Surgery, Medical School, University of the the area. If the area contains structures of varying density, Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, each structure contributes proportionally to the HU. Very South Africa. highor low-density objects contribute corresponding density values, which when averaged with the rest of the structures in the volume result in abnormally high or low HU being assigned to the entire area. This is termed the partial volume effect. The effect may be minimized by using finer slice thicknesses to limit the volume included in each slice (Wegener, 1983). Although in this patient the CT slices had been only 3 mm thick, partial volume effect resulted in poor visualization of the denser foreign body lying as it did within the air track. Since in the normal course of events pockets of air are absorbed within days, a persistent air track should alert the clinician to the possibility of a foreign body. A detailed search for radiologically subtle foreign objects should always follow. Awareness of this may help avoid the pitfall created by the partial volume artefact, and encourage an active search using all available modalities to detect any inconspicuous object.

Clinical and immunological correlates of chest X‐ray abnormalities in HIV‐infected South African children with limited access to anti‐retroviral therapy

The chest X‐ray (CXR) abnormalities of human immunodeficiency virus (HIV)‐infected children in low/middle income countries (LMICs) have not been well studied.

Chest radiographic presenting features and radiographic progression of pneumocystis pneumonia in South African children

To describe the radiographic features of PCP in South African children, including the progression of changes and the impact of HIV‐infection and respiratory co‐infections.

Chest radiographic abnormalities in HIV-infected African children: a longitudinal study

Background There is limited knowledge of chest radiographic abnormalities over time in HIV-infected children in resource-limited settings. Objective To investigate the natural history of chest radiographic abnormalities in HIV-infected African children, and the impact of antiretroviral therapy (ART). Methods Prospective longitudinal study of the association of chest radiographic findings with clinical and immunological parameters. Chest radiographs were performed at enrolment, 6-monthly, when initiating ART and if indicated clinically. Radiographic abnormalities were classified as normal, mild or moderate severity and considered persistent if present for 6 consecutive months or longer. An ordinal multiple logistic regression model assessed the association of enrolment and time-dependent variables with temporal radiographic findings. Results 258 children (median (IQR) age: 28 (13–51) months; median CD4+%: 21 (15–24)) were followed for a median of 24 (18–42) months. 70 (27%) were on ART at enrolment; 130 (50%) (median age: 33 (18–56) months) commenced ART during the study. 154 (60%) had persistent severe radiographic abnormalities, with median duration 18 (6–24) months. Among children on ART, 69% of radiographic changes across all 6-month transition periods were improvements, compared with 45% in those not on ART. Radiographic severity was associated with previous radiographic severity (OR=120.80; 95% CI 68.71 to 212.38), lack of ART (OR=1.72; 95% CI 1.29 to 2.27), enrolment age <18 months (OR=1.39; 95% CI 1.06 to 1.83), diffuse, severe radiographic abnormality at enrolment (OR=2.18; 95% CI 1.33 to 3.56), hospitalisation for lower respiratory tract infection during the previous 6 months (OR=1.88; 95% CI 1.06 to 3.30) and length of follow-up: at 18–24 months (OR=0.66; 95% CI 0.49 to 0.90), and at 30–54 months (OR=0.42; 95% CI 0.32 to 0.56). Conclusions Most children had severe radiographic abnormalities persisting for at least 18 months. ART was beneficial, reducing the risk of radiographic deterioration or increasing the likelihood of radiological improvement.

The chest X-ray features of chronic respiratory disease in HIV-infected children – a review

Several features of human immunodeficiency virus (HIV) infection contribute to the development of chronic respiratory disease in children. These include the frequency and severity of acute chest infections, as well as the increased risk of pulmonary tuberculosis, aspiration, cardiovascular disease, lymphocytic interstitial pneumonitis or pulmonary neoplasia. The chest radiograph (CXR) remains the most accessible investigation for respiratory disease and plays an important role in the baseline assessment and follow-up. This review focuses on the CXR abnormalities of HIV-related chronic respiratory disease in children. The most commonly documented chronic CXR abnormalities are homogeneous opacification and pulmonary nodules, with pulmonary tuberculosis and lymphocytic interstitial pneumonitis the leading respective causes. Deficiencies in radiographic reporting methodology and relative paucity of radiographic data contribute to current limitations in knowledge and understanding of this field. The review highlights the need for standardised terminology and systematic reporting methodology in future studies. Prospective research on the natural history of lymphocytic interstitial pneumonitis, response to anti-tuberculous therapy, the impact of anti-retroviral therapy and HIV-associated bronchiectasis are needed.

Delayed presentation of haemobilia after penetrating liver injury

Sir, We read with interest the case report describing haemobilia that presented 2 weeks after a thoracic stab wound 1. The authors indicate that the case is unusual because of the exceptional length of delay and thoracic stabbing as a cause. We have treated 10 patients, 9 men and 1 woman, with post-traumatic haemobilia, ages ranging from 17 to 44 years (mean age 27 years) over a 36-year period 2. There were eight grade 3 injuries and two grade 4 liver injuries due to penetrating stab wounds in eight patients and blunt trauma in two patients. The mean delay between the initial liver injury and the diagnosis of haemobilia was 23.5 days (range 1–120 days). Only 4 of the 10 patients presented within 1 week of the injury. Three of the stab wounds presented 13, 14 and 60 days after the injury. One patient with a grade 4 blunt liver injury after a motor vehicle accident (MVA) presented 120 days after the injury. Similar delays in presentation were documented in the study from Durban, with a mean delay of 16 days (range 7–211 days) 3. We agree that selective hepatic artery embolization using either 5 Fr Cobra or similar catheters passed over hydrophilic or Teflon-coated guide wires is the optimal treatment, supplemented by 3 Fr microcatheters when needed. Where possible, an attempt should be made to straddle the arterial injury site by placing coils or other occlusive agents on both sides of the injury to prevent possible retrograde flow and bleeding from intrahepatic arterial collaterals 2. Recanalization may occur in some patients when proximal gelatin sponge or even coils have been used. Gelatin sponge usually reabsorbs within a few weeks, potentially resulting in free bleeding if complete healing of the injury has not occurred, as in chronic causes. The data suggest that delayed presentation of haemobilia is common both after blunt and penetrating liver injuries and that selective hepatic artery embolization with careful placement of coils or other, preferably non-absorbable material, provides optimal treatment.