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CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided. A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined. A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001). There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

To compare quantitative chest CT parameters in perinatally HIV-infected adolescents with and without bronchiolitis obliterans compared with HIV-uninfected controls and their association with lung function measurements. Seventy-eight (41 girls) HIV-infected adolescents with a mean age of 13.8 ± 1.65 years and abnormal pulmonary function tests in the prospective Cape Town Adolescent Antiretroviral Cohort underwent contrast-enhanced chest CT on inspiration and expiration. Sixteen age-, sex-, and height-matched non-infected controls were identified retrospectively. Fifty-one HIV-infected adolescents (28 girls) displayed mosaic attenuation on expiration suggesting bronchiolitis obliterans. Pulmonary function tests were collected. The following parameters were obtained: low- and high-attenuation areas, mean lung density, kurtosis, skewness, ventilation heterogeneity, lung mass, and volume. HIV-infected adolescents showed a significantly higher mean lung density, ventilation heterogeneity, mass, and high- and low-attenuation areas compared with non-infected individuals. Kurtosis and skewness were significantly lower as well. HIV-infected adolescents with bronchiolitis obliterans had a significantly lower kurtosis and skewness compared with those without bronchiolitis obliterans. Lung mass and volume showed the strongest correlations with forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and alveolar volume. Low-attenuation areas below – 950 HU and ventilation heterogeneity showed the strongest correlation with FEV1/FVC (range, − 0.51 to − 0.34) and forced expiratory flow between 25 and 75% of FVC (range, − 0.50 to − 0.35). Quantitative chest CT on inspiration is a feasible technique to differentiate perinatally HIV-infected adolescents with and without bronchiolitis obliterans. Quantitative CT parameters correlate with spirometric measurements of small-airway disease. • Perinatally HIV-infected adolescents showed a more heterogeneous attenuation of the lung parenchyma with a higher percentage of low- and high-attenuation areas compared with non-infected patients. • Kurtosis and skewness are able to differentiate between HIV-infected adolescents with and without bronchiolitis obliterans using an inspiratory chest CT. • Quantitative CT parameters of the chest correlate significantly with pulmonary function test. Low-attenuation areas and ventilation heterogeneity are particularly associated with spirometric parameters related to airway obstruction.

Introduction A computed tomography (CT) brain scan is an often-utilised emergency department imaging modality to detect emergent intra-cranial pathology in a child with a first seizure. Identifying children at low risk of having a clinically significant intra-cranial abnormality could prevent unnecessary radiation exposure and contrast/sedation-related risks. Objectives To identify clinical variables which could predict clinically significant CT brain abnormalities and use recursive partitioning analysis to define a low-risk group of children in whom emergent CT brain can be deferred. Methods Retrospective cross-sectional review of 468 children who underwent emergent CT brain after presenting to a low- and middle-income paediatric emergency department following first seizure. Results In total 133/468 (28.4%) of CT brain scans had clinically significant abnormalities. Failure to return to neurological baseline and focal neurological deficit persisting >36 h had statistical significance in a multiple regression analysis. Recursive partitioning analysis, applied to a subgroup without suspected tuberculous meningitis (n = 414), classified 153 children aged between 6 months and 5 years, who had a normal neurological baseline, had returned to baseline post-seizure, and were not in status epilepticus, as non-clinically significant scans and 98% were correctly classified. Conclusion Our study re-inforces the American Academy of Neurology recommendation that children with persistent post-ictal abnormal neurological status and/or post-ictal focal deficit be prioritised for emergent CT brain. Having excluded children with suspected tuberculous meningitis, the remaining subgroup aged 6 months to 5 years presenting with a non-status first seizure, normal neurological baseline and return to baseline post-seizure, are at very low risk of having a clinically significant CT brain abnormality.

INTRODUCTION Chronic lung disease is common in perinatally HIV-infected children as they increasingly surviving into adolescence. There are few data on the radiologic spectrum of disease in this population. METHODS Contrasted high-resolution computed tomography (HRCT) was performed in ambulatory South African adolescents enrolled in a prospective study of perinatally-infected adolescents aged 9 to 14 years established on combined antiretroviral therapy (cART) and followed for 36 months. Consecutive participants with reduced lung function (defined by a forced expiratory volume in 1 second [FEV1] of

Early treatment with combination antiretroviral therapy (cART) has improved survival of children perinatally infected with HIV into adolescence. This population is at risk of long term complications related to HIV infection, particularly chronic respiratory disease. Limited data on chest imaging findings in HIV-infected adolescents, suggest that the predominant disease is of small and large airways: predominantly bronchiolitis obliterans or bronchiectasis. Single cases of emphysema have been reported. Lung fibrosis, lymphocytic interstitial pneumonitis, post tuberculous apical fibrocystic changes and malignancies do not feature in this population. Chest radiograph (CXR) is easily accessible and widely used, especially in resource limited settings, such as sub Saharan Africa, where the greatest burden of HIV disease occurs. Lung ultrasound has been described for the diagnosis of pneumonia in children, pulmonary oedema and interstitial lung disease [1-3]. The use of this modality in chronic respiratory disease in adolescents where the predominant finding is small airway disease and bronchiectasis has however not been described. CXR is useful to evaluate structural/post infective changes, parenchymal opacification and nodules, hyperinflation or extensive bronchiectasis. CXR however, is inadequate for diagnosing small airway disease, for which high resolution computed tomography (HRCT) is the modality of choice. Where available, low dose HRCT should be used early in the course of symptomatic disease in adolescents and for follow up in children who are non responsive to treatment or clinically deteriorating. This article provides a pictorial review of the spectrum of CXR and HRCT imaging findings of chronic pulmonary disease in perinatally HIV-infected adolescents on cART and guidelines for imaging.

Background: Lupus myocarditis (LM) occurs in 5-10% of patients with systemic lupus erythematosus (SLE). Subclinical myocardial inflammation occurs in 37% at post mortem.1 Echocardiographic strain (STE) supports subclinical myocardial dysfunction in SLE.2 Tissue characterisation by cardiac magnetic resonance (CMR) identifies myocardial inflammation, necrosis and/or fibrosis, detecting clinical and subclinical myocardial injury (MIN) in SLE. It‘s the non-invasive gold standard for diagnosing myocarditis (all types) based on the Lake Louise criteria (LLC).3 Objectives: Determine prevalence of MIN in SLE (LLC). Compare clinical and echocardiographic (echo) features of patients with and without MIN. Identify echo predictors of MIN. Methods: A prospective crossectional study was done at Tygerberg Hospital, Western Cape, South Africa. Adult inpatients, fulfilling the 2012 SLICC criteria were screened. Echo analyses included STE and regional function (wall motion score (WMS)). Patients were grouped according to evidence of MIN (absent criteria [AC]; single criterion [SAC]; fulfilling LLC), comparing clinical, laboratory and echo data. Logistic regression and ROC were used to determine predictors of MIN. Results: 49/106 SLE patients screened were included (Figure 1). 46.9% of patients had MIN (≥1 criterion): 12.2% fulfilled LLC for LM and 34.7% had a SAC. SLE disease activity (SLEDAI) (p=0.022) was higher in patients fulfilling LLC, but not in the SAC group. A clinical and echo diagnosis of LM was made in all patients fulfilling LLC, in 17.6% of patients in the SAC group and none in the AC group (Table 1). Anti-DsDNA and anti-B2GP1 were more frequently positive in SAC vs the AC group (p=0.054 and 0.081). WMS was higher in LLC and SAC groups (p=0.006;p=0.083) with mid and basal STE more impaired in patients with MIN (p=0.047;p=0.043). LVID and mid STE score combined was the best predictor of MIN (Table 2; Figure 2). Conclusion: CMR evidence of MIN is common in SLE, even in the absence of clinical myocardial dysfunction or high lupus activity. Impaired echo regional and global function occurs more frequently in patients with MIN. STE combined with LVID predicts MIN detected by CMR and has potential as a cost effective screening tool. CMR is limited by a high exclusion rate in SLE, mainly due to renal impairment. References: [1] Panchal L, et al. Cardiovascular involvement in systemic lupus erythematosus: an autopsy study of 27 patients in India. J Postgrad Med. 2006;52:5-10. [2] Gusetu G, et al. Subclinical myocardial impairment in SLE: insights from novel ultrasound techniques and clinical determinants. Med Ultrason. 2016;18:47-56. [3] Friedrich M, et al. Cardiovascular Magnetic Resonance in Myocarditis: A JACC White Paper. J Am Coll Cardiol. 2009;53:1475–87. Disclosure of Interests: Riette du Toit Grant/research support from: I received a sponsorship to attend EULAR 2018 from Pfizer. I have received a donation form ROCHE in 2018 for upgrading of our outpatient clinical area in Tygerberg Hospital., Phillip Herbst: None declared, Alfonso JK Pecoraro: None declared, Christelle Ackerman: None declared, Anne-Marie du Plessis: None declared, Helmuth Reuter Speakers bureau: Received Honorarium as speaker at regional meetings, South Africa, Anton F Doubell: None declared

The recently proposed diagnostic algorithm for progressive multifocal leukoencephalopathy underscores the importance of imaging and emphasizes the role of the radiologist in the diagnostic workup. We describe a case series of patients with visual symptoms and a typical pattern of brain involvement in definite progressive multifocal leukoencephalopathy, for which we have coined the term barbell sign.

Background There has been no detailed analysis of the cause of intrathoracic large airway obstruction in infants in a resource-limited environment with a high prevalence of pulmonary tuberculosis (PTB) and human immunodeficiency virus (HIV). Aim To define the aetiology and severity of intrathoracic large airway obstruction in infants in a tertiary South African hospital with a high prevalence of PTB and HIV. Methods A retrospective study of infants was conducted with computerised tomography (CT) evidence of intrathoracic large airway obstruction from 1 January 2011 to 31 May 2014. CT scans were evaluated for the cause, site and severity of airway narrowing, with severity stratified as 'mild' (50%), 'moderate' (51-75%) or 'severe' (75%). Results Forty-four patients (28 males, 64%; median age 145 days, range 5-331), and 79 sites of attenuation were included. Vascular (22/44, 50%) and nodal (18/44, 41%) compressions accounted for over 90% of cases. Thirty-five patients (79.5%) had at least one site of moderate/severe attenuation, and 26 (59%) had multiple such sites. Adenopathy was the commonest cause of moderate/severe compression (18/35, 51%). All cases of nodal compression were of tuberculous origin. HIV-serology was recorded in 32 patients (73%), one of whom, with vascular compression, was HIV-infected. Half of the patients (11/22, 50%) with vascular compression had congenital abnormalities, most commonly cardiac anomalies (7/22, 32%). There were no synchronous vascular and nodal compressions. Conclusion Infantile intrathoracic large airway obstruction where there is a high prevalence of PTB and HIV is characterised by its extrinsic aetiology, severity and multicentricity, with more than half of all moderate/severe obstructions being caused by tuberculous adenopathy.

No Abstract.

This pictorial essay provides a classification system for the most common intramedullaryspinal masses and describes distinguishing imaging features that will aid the radiologist inproviding a relevant differential diagnosis to guide further management.

Vertically transmitted HIV infection is a major problem in the developing world due to the poor availability of antiretroviral agents to pregnant women. HIV is a neurotrophic virus and causes devastating neurological insults to the immature brain. The effects of the virus are further compounded by the opportunistic infections and neoplasms that occur as a result of the associated immune suppression. This review focuses on the imaging features of HIV infection and its complications in the central nervous system.

Artefacts reflect problems with radiographic technique rather than true pathology. These may be misinterpreted as pathology with serious consequences. An artefact caused such problems in one paediatric imaging department. To determine the incidence, and consequences of misinterpretation, of a CT artefact in a paediatric imaging department. A retrospective review of images and reports of paediatric CT scans over a set period with a known artefact was performed. Reports were correlated with reviewers’ evaluation of the presence of artefact and reviewed for correct identification of artefact, misinterpretation as pathology, and action taken as a result. A total of 74 CT scans had been performed over the study period and an artefact detected by reviewers on 32 (43%). Six (18.75%) of these were misinterpreted as pathology, of which three (9.4%) were reported as tuberculous granulomas, two (6.2%) as haemorrhages and one (3.1%) as an unknown hyperdensity. Two patients (6.2%) had subsequent MRI studies performed, and treatment for tuberculosis was continued in one patient (3.1%). No initial report identified the artefact. One-fifth of the scans with the artefact were misinterpreted as pathology and half of these misinterpretations led to further action. Artefacts result in false diagnoses and unnecessary investigations; vigilance is needed.

We present a 5-month-old boy with bridging bronchus associated with a sling left pulmonary artery, both of which are rare. Coronal CT using 3-D volume rendering technique was used to delineate the abnormality and plan surgery. We propose that this technique could be used as single diagnostic tool in a child who presents, as children with this anomaly do, with chronic or recurrent lower respiratory tract infections.

In their recent article, Apffelstaedt et al. 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.

DiagnosisUlnar club hand/ ulnar dysplasia [type I variant].DiscussionUlnar club hand, also known as ulnar dysplasia or postaxiallongitudinal deficiency, is a rare condition with anincidence reported by some authors to be as low as1:1,000,000 [1]. The abnormality occurs as a result ofdistal tethering of the ulnar fibrocartilaginous structure tothe carpus, with resulting bowing of the radius. Most casesare sporadic and causes include postinfective [2]. Associ-ation with rare inherited disorders such as Klipple Feil andulnar mammary syndrome as well as nongenetic syn-dromes such as Cornelia de Lange has also been reported[1,3]. Associated major organ system malformations areuncommon though musculoskeletal malformations, such asphocomelia, aphalangia and radial deficiency, are seen inup to 50% of cases [3].Patients usually present with a foreshortened, internallyrotated forearm with associated hand malformations. Dis-location of the radius head (present in our patient) withdecreased range of movement of the elbow is reported in40% of cases [3].The condition was classified by Bayne according tomusculoskeletal abnormalities of the elbow and forearminto four groups [3]. Type I presents with hypoplasia ofthe ulna, both proximal and distal ulnar physes present andnonprogressive radial bowing. Type II consists of apartially absent radius, a fibrous anlage extending to thecarpus from the distal ulna, radial bowing and ulnardeviation of the hand. Type III involves absence of theulna with no anlage present, unstable elbow due to absentolecranon and radius, wrist and hand are usually straight.Type IV presents with synostosis of the distal humerus andproximal radius with marked radial bowing and an ulnaranlage extending from the humerus to the carpus. Ourpatient was classified as type I due to the presence of acompletely bowed radius, visible proximal ulnar cartilagestructures and trochlea as well as the probable fibrousanlage distally.Further classification on the basis of presenting handmalformations was established by Cole and Manske andthey divided the dysplasia into four types based on the firstwebspace and the thumb. Type A presents with a normalthumb and webspace, type B with contracture of thewebspace, type C with hypoplasia and rotation of thewebspace into motion plane of the other digits and type Dpresents with an absent thumb [3]. These classifications aremostly used by clinicians to establish a treatment protocolfor patients, which are mostly designed to improve functionand address cosmetic concerns. Our patient presented with