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    ABSTRACT: Malignant biliary obstruction is often inoperable at presentation and has a poor prognosis. Percutaneously placed self-expanding metal stents (SEMS) have been widely used for palliation of malignant biliary obstruction as an alternative to major bypass surgery or when endoscopic drainage is not technically feasible. The success rate, procedural complications and outcomes in patients who underwent placement of SEMS in a tertiary referral centre are presented. All patients who had percutaneous transhepatic cholangiography (PTC) and SEMS for palliation of malignant biliary obstruction between May 2008 and July 2010 at Groote Schuur Hospital, Cape Town, were reviewed. A retrospective chart review was undertaken using multidisciplinary case notes of all patients. The data analysed included demographic information, diagnosis, level of biliary obstruction, number and type of procedures, efficacy and complications of SEMS insertion. Boston Scientific 69 mm by 10 mm Wallstent SEMS were used in all patients. RESULTS; Fifty patients (28 men, 22 women, mean age 61 years, range 48 - 80 years) underwent percutaneous SEMS placement. Twenty-one patients had biliary obstruction at the level of the hilum involving the hepatic duct bifurcation, 5 in the mid-common bile duct and 24 in the low common bile duct. In 20 patients (40%) SEMS were placed at the time of initial biliary drainage (one-stage procedure), while the remaining 30 patients underwent stent placement within 2 - 23 days of biliary drainage as a two-stage procedure because of difficult access through the lesion during the initial procedure. Five patients (10%) required bilateral SEMS insertion. Stent placement was successful in all patients and biliary obstruction was relieved in all. The mean serum bilirubin level decreased by a mean of 56% from 294 µmol/l to 129 µmol/l measured 5 days after stent insertion. Mean hospital stay after stent insertion was 4.1 days. The average length of hospital stay for patients who underwent a one-stage procedure was 3.2 days (range 1 - 11 days), and for patients who underwent a two-stage procedure 7.6 days (range 3 - 23 days). Nine patients (18%) developed a procedure-related complication, which included cholangitis after stent insertion (n=4), cholangitic liver abscesses (n=1), subphrenic liver collection (n=1), bile leakage (n=1) and cholecystitis (n=2). Three patients (6%) developed complications unrelated to SEMS insertion, which included myocardial ischaemia (n=2) and pneumonia (n=1). Stent occlusion occurred in 4 patients (8%) within a week as result of stent migration (n=3) or presumed biliary sludge (n=1); 2 (4%) stents occluded between 7 days and 1 month. Four patients (8%) died during hospital admission due to pre-existing biliary sepsis (n=3) and pneumonia (n=1). Nine patients developed duodenal obstruction due to disease progression and required endoscopic duodenal stenting. Four patients (8%) survived less than 1 month, 12 (24%) between 1 month and 3 months, 11 (22%) between 3 and 6 months, and 10 (20%) beyond 6 months. Follow-up was not possible for 9 patients (18%) from distant referral sites. These results demonstrate that percutaneously placed SEMS achieved satisfactory palliation with a low complication rate in a high-risk patient group with advanced malignant biliary obstruction.
    South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie 08/2012; 50(3):54, 56, 58 passim. DOI:10.7196/sajs.1302
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    ABSTRACT: 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. 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. 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. 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. Pericardial and abdominal ultrasound examinations are valuable supplementary investigations in the diagnosis of suspected extrapulmonary or disseminated TB.
    South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 01/2011; 101(1):39-42.
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    ABSTRACT: We present two children beyond the neonatal and infant age who suffered global hypoxic events and showed an MRI appearance of reversal of the diffusion-weighted (DWI) and apparent diffusion coefficient (ADC) signal involving exclusively the white matter. This is an unusual distribution for this age group and may represent delayed postanoxic leukoencephalopathy. The appearance of this type of insult has been described as occurring in younger children more frequently than in adults. Awareness of this condition, the fact that it may occur earlier, and the peculiar and possibly deceptive DWI/ADC signal reversal pattern exclusively involving the white matter is critical for making a correct diagnosis and giving a prognosis.
    Pediatric Radiology 02/2009; 39(3):293-8. DOI:10.1007/s00247-008-1095-3
  • Pediatric Radiology 12/2005; 35(11):1159-60. DOI:10.1007/s00247-005-1544-1
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    ABSTRACT: The value of CT in the diagnosis of tuberculous meningitis (TBM) in children is well reported. Follow-up CT scanning for these patients is, however, not well described and, in particular, the value of early follow-up CT has not been addressed for children with TBM. To assess the value of early follow-up CT in children with TBM in identifying diagnostic, prognostic and therapeutically relevant features of TBM. A retrospective 4-year review of CT scans performed within 1 week and 1 month of initial CT in children with proven (CSF culture-positive) and probable TBM (CSF profile-positive but culture-negative) and comparison with initial CT for the diagnostic, prognostic and therapeutic CT features of TBM. The CT scans of 50 children were included (19 "definite" TBM; 31 "probable" TBM). Of these, 30 had CT scans performed within 1 week of the initial CT. On initial CT, 44 patients had basal enhancement. Only 24 patients had contrast medium-enhanced follow-up scans. Important findings include: 8 of 29 patients (who were not shunted) developed new hydrocephalus. New infarcts developed in 24 patients; 45% of those who did not have infarction initially developed new infarcts. Three of the six patients who did not show basal enhancement on initial scans developed this on the follow-up scans, while in seven patients with pre-existing basal enhancement this became more pronounced. Two patients developed hyperdensity in the cisterns on non-contrast medium scans. Eight patients developed a diagnostic triad of features. Three patients developed CT features of TBM where there was none on the initial scans. Early follow-up CT is useful in making a diagnosis of TBM by demonstrating features that were not present initially and by demonstrating more sensitive, obvious or additional features of TBM. In addition, follow-up CT is valuable as a prognostic indicator as it demonstrates additional infarcts which may have developed or become more visible since the initial study. Lastly, follow-up CT has therapeutic value in demonstrating hydrocephalus, which may develop over time and may require drainage. We advise routine follow-up CT in patients with suspected TBM within the first week of initial CT and optionally at 1 month.
    Pediatric Radiology 12/2005; 35(11):1092-9. DOI:10.1007/s00247-005-1549-9
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    South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 07/2003; 93(6):426-8.
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    ABSTRACT: The purpose of this study was to evaluate the diagnostic equivalence, radiation dose, clinical usefulness and radiographic aspects of a low-dose, full-body digital X-ray machine in a busy trauma unit. A digital trauma X-ray machine known as "LODOX" was compared with conventional radiography between June 1999 and November 2001 in the Groote Schuur Hospital Trauma Unit, Cape Town. Digital images of a variety of body regions commonly imaged in trauma were compared for diagnostic image quality in a number of categories with equivalent conventional radiographs. A seven-point equivalence scoring system ranging from much inferior (-3) through equivalent (0) to much superior (+3) was used in each category. Radiation dose was recorded and compared with that in conventional measurements. Turnaround times of patients undergoing digital and conventional X-rays were evaluated. Clinical and radiographic issues were assessed by staff feedback. The digital images when compared with conventional film had an overall mean equivalence score of -0.429, with a standard deviation (SD) of 0.77. The best digital performance was in the mediastinum (mean 0.346, SD 0.49) and the weakest was for bony detail (mean -0.654, SD 0.81). Relative digital radiation dose compared to conventional varied from 72% (chest) to 2% (pelvis), with a simple average of 6%. Radiographic points included full-body imaging capability and differing positioning, penetration, workflow and practicality considerations. The digital images required overall patient times of 5-6 min, compared with 8-48 min for conventional X-rays. New installations are under way, and computed tomography and angiography applications are being explored. FDA approval is awaited. Projected cost is similar to that of flat-panel digital units. This digital unit was felt to be diagnostically substantially equivalent to conventional radiographs, with low-dose full-body imaging, improved workflow, digital technology and long-term cost benefits as potentially favourable contributions to trauma imaging.
    Emergency Radiology 05/2003; 10(1):23-9. DOI:10.1007/s10140-003-0271-x
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    ABSTRACT: The aim of this article is to report the MRI features of bilateral parotid haemangiomas of infancy and highlight the diagnostic and prognostic value of MRI especially with regard to those lesions that may cause respiratory compromise. Retrospective review of MRI scans in six infants with bilateral parotid haemangiomas. The bilateral haemangiomas were symmetrical in all but one patient. On T1-weighted images the masses were isointense to muscle and on T2 they were hyperintense with numerous small vessels giving a septated appearance. There was vivid enhancement with gadolinium in all cases. In three patients, deep bilateral extensions were demonstrated involving the parapharyngeal spaces resulting in respiratory compromise which required tracheostomy. Bilateral parotid haemangiomas are rare, but when present may have deep extensions, which can result in respiratory compromise requiring tracheostomy.
    European Radiology 05/2003; 13(4):711-6. DOI:10.1007/s00330-002-1623-8
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    ABSTRACT: A rare case of a gastric duplication in the tail of the pancreas in a child presenting with recurrent abdominal pain and evidence of pancreatic calcification suggesting pancreatitis was cured by excision of the cyst and adjacent pancreas. Congenital causes of pancreatitis are rare, but are curable with surgery. These lesions are often misdiagnosed, and patients may be subjected to inappropriate surgery. Imaging is sensitive in the detection of such lesions, but the lack of specific features necessitates an index of suspicion. Similar cases have been described previously, but the pancreatic tail is rarely involved.
    Pediatric Surgery International 04/2002; 18(2-3):190-2. DOI:10.1007/s003830100673
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    ABSTRACT: A case is described in which a myocardial infarction in a young woman was associated with a congenital aneurysm of the left coronary artery. Coronary angiography had shown displacement and almost total occlusion of the left circumflex artery. MRI demonstrated that this was owing to an aneurysm of the left circumflex coronary artery.
    British Journal of Radiology 04/2000; 73(867):322-4. DOI:10.1259/bjr.73.867.10817051
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South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 02/2007; 97(2):98-9.
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