Browsing by Author "Andronikou, Savvas"

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    Open Access
    An appropriateness review of urgent in-hours nontrauma CT brain scans at a single tertiary referral centre in South Africa - are we scanning rationally?
    (2019) Jacobs, Donovan George; Andronikou, Savvas
    Aim: To determine if urgent, non-trauma in-hours CT head scan requests in the GSH department of radiology are being appropriately requested and completed, as well as determining the radiation dose for each study. Secondly, to make recommendations to improve local practice based on the findings of this study. Methods: A retrospective study was undertaken of 100 qualifying in-hours urgent, nontrauma CT head scans completed at the GSH department of radiology between 01/10/2015 and 31/03/2016. All qualifying CT request data and dose records were collected and anonymised, after ethical and institutional approval. Three radiologists at GSH were enlisted to review the request information. Each request was reviewed and categorised by both the researcher and each consultant individually to determine the indication and appropriateness. The researcher used previously published, objective criteria (Rothrock Criteria) to review requests, while the radiologists used their own interpretation of accepted local practice. The researcher recorded positive and negative scan outcomes, radiation doses and calculated the Effective Dose (ED) for each study. Results were recorded in Excel and statistical analysis using weighted Kappa analysis was undertaken. Results: Study cohort CT scans made up 15.6% of the total emergency head CT scans over the study period. The mean patient age was 52.3 years (range: 18.8-87.4 years). One-third (34; 34%) were older than 60 years with 33 (97%) having at least 2 positive Rothrock criteria. Most CT scans (86%) consisted of a single study, while the remaining comprised two or more. Average ED was 3.27 mSv (range: 1.03-4.33 mSv). 52 (52%) participants had abnormal CT findings, independent of age-group. Discrepancy in assigning study indication and appropriateness between the researcher and consultants was present, with at best moderate agreement (weighted-Kappa range 0.09-0.52). The researcher showed slight to fair agreement between scan outcome and request appropriateness using the Rothrock criteria (weighted kappa 0.20; 95% CI: 0.06-0.35, p=.00861), while the consultant consensus performed slightly worse (0.10; 95% CI: -0.05-0.26, p=.19728). Conclusion: Retrospective application of the Rothrock criteria to patient referrals produced better correlation with outcome than current departmental practice. However, there is at best moderate agreement between consultants with regard to classification of referrals which could negatively affect the application of Rothrock criteria in practice. Incorporating the Rothrock criteria into published departmental guidelines, in conjunction with other interventions to improve clinician requesting practices, is recommended. The formation of a Quality Assurance team and the use of existing dose-reducing techniques may assist in reducing radiation doses further.
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    Chest Imaging for Pulmonary TB—An Update
    (2022-01-26) Nel, Michael; Franckling-Smith, Zoe; Pillay, Tanyia; Andronikou, Savvas; Zar, Heather J
    The diagnosis of pulmonary tuberculosis (PTB) in children is challenging. Difficulties in acquiring suitable specimens, pauci-bacillary load, and limitations of current diagnostic methods often make microbiological confirmation difficult. Chest imaging provides an additional diagnostic modality that is frequently used in clinical practice. Chest imaging can also provide insight into treatment response and identify development of disease complications. Despite widespread use, chest radiographs are usually non-specific and have high inter- and intra-observer variability. Other diagnostic imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can provide additional information to substantiate diagnosis. In this review, we discuss the radiological features of PTB in each modality, highlighting the advantages and limitations of each. We also address newer imaging technologies and potential use.
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    Corpus callosum morphology in children on mid-sagittal MR imaging
    (2018) Raubenheimer, Lauren; Andronikou, Savvas; Kilborn,Tracy
    Background: There is little published research on the wide variation of corpus callosum (CC) morphology in children, the assessment of which is made difficult by the complex alteration of its appearance in childhood. Objective: The purpose of our study was to assess the morphology of the CC on mid-sagittal T1- weighted magnetic resonance imaging (MRI) in a large number of children and correlate the findings with demographic and clinical criteria. Materials and methods: We reviewed all brain mid-sagittal T1-weighted MRI’s performed from July to December 2015 and obtained relevant demographic and clinical information from the accompanying report and laboratory system. The CC morphology was analysed by three radiologists and compared using cross tabulation with the chi-square test and ANOVA. Interobserver correlation was assessed using Kappa coefficient of conformance. Results: 257 patients with mean age 72±60 months were included, 142 were male (55%). In abnormal MRI’s the CC was less likely to have an identifiable isthmus and was more likely to be convex, thin and have separation of the fornix insertion (all p<0.01). In young children (< 5 years) the CC was also less likely to have an identifiable isthmus (p=0.01) and was more likely to be convex (p=0.04) but the fornix was more likely to insert normally (p<0.01). Children with tuberous sclerosis had significantly thinner splenia (p=0.02). Conclusion: There is a distinct pathological appearance of the CC. The immature appearance of the corpus callosum can mirror this but is distinguished by normal insertion of the fornix and normal quantitative measurements. Splenial thinning in children with tuberous sclerosis warrants further investigation.
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    Open Access
    Diffusion tensor imaging point to ongoing functional impairment in HIV-infected children at age 5, undetectable using standard neurodevelopmental assessments
    (2020-05-19) Ackermann, Christelle; Andronikou, Savvas; Saleh, Muhammad G; Kidd, Martin; Cotton, Mark F; Meintjes, Ernesta M; Laughton, Barbara
    Background Perinatal HIV infection negatively impacts cognitive functioning of children, main domains affected are working memory, processing speed and executive function. Early ART, even when interrupted, improves neurodevelopmental outcomes. Diffusion tension imaging (DTI) is a sensitive tool assessing white matter damage. We hypothesised that white matter measures in regions showing HIV-related alterations will be associated with lower neurodevelopmental scores in specific domains related to the functionality of the affected tracts. Methods DTI was performed on children in a neurodevelopmental sub study from the Children with HIV Early Antiretroviral (CHER) trial. Voxel-based group comparisons to determine regions where fractional anisotropy and mean diffusion differed between HIV+ and uninfected children were done. Locations of clusters showing group differences were identified using the Harvard–Oxford cortical and subcortical and John Hopkins University WM tractography atlases provided in FSL. This is a second review of DTI data in this cohort, which was reported in a previous study. Neurodevelopmental assessments including GMDS and Beery-Buktenica tests were performed and correlated with DTI parameters in abnormal white matter. Results 38 HIV+ children (14 male, mean age 64.7 months) and 11 controls (4 male, mean age 67.7 months) were imaged. Two clusters with lower fractional anisotropy and 7 clusters with increased mean diffusion were identified in the HIV+ group. The only neurodevelopmental domain with a trend of difference between the HIV+ children and controls (p = 0.08), was Personal Social Quotient which correlated to improved myelination of the forceps minor in the control group. As a combined group there was a negative correlation between visual perception and radial diffusion in the right superior longitudinal fasciculus and left inferior longitudinal fasciculus, which may be related to the fact that these tracts, forming part of the visual perception pathway, are at a crucial state of development at age 5. Conclusion Even directed neurodevelopmental tests will underestimate the degree of microstructural white matter damage detected by DTI. The visual perception deficit detected in the entire study population should be further examined in a larger study.
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    Evaluation of the Diagnostic Performance of Lung Ultrasound Compared to Chest X-rays for Diagnosis of Pneumonia in Children
    (2019) Stadler, Jacob A M; Zar, Heather; Andronikou, Savvas
    Pneumonia remains a global health priority in children. It is the leading cause of death in children outside the neonatal period, over 90% of which occur in low-resource settings, and a major cause of morbidity, accounting for over 100 million episodes globally each year. Early, correct diagnosis is a modifiable factor which can potentially improve pneumonia outcomes. Current guidelines recommend the use of clinical signs and symptoms alone to make a diagnosis of pneumonia in low risk, ambulatory cases with clinically mild disease. However, clinical diagnosis lacks specificity and may lead to antibiotic overuse and drive antibiotic resistance. Addition of chest X-ray (CXR) to diagnostic algorithms improves specificity, but CXR use is limited by radiation exposure and relatively high costs, limiting access in low-resource settings. Current guidelines therefore reserve CXR for moderate to severe disease and hospitalised cases, even in well-resourced settings. Lung ultrasound (LUS) is a promising imaging modality which uses no radiation, is less costly than CXR and can improve the time to results when used as a point-of-care tool by clinicians outside the radiology department. These characteristics make LUS, at least theoretically, a potential option either as add-on screening test aimed at decreasing unnecessary antibiotic prescription or as a lower risk, lower cost definitive diagnostic test capable of replacing CXR, or both. The objective of this study was to understand the role of LUS as a diagnostic test for pneumonia in children by performing a structured literature review and metaanalysis summarizing the current evidence comparing diagnostic performance of LUS and CXR, and by reporting previously unpublished data from the Drakenstein Child Health Study comparing diagnostic performance of LUS and CXR for pneumonia in children in a resource-constrained, African setting.
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    Evaluation of the utility of specific CXR features for diagnosis of pulmonary tuberculosis in young children using multiple readers
    (2015) Ho-Yee, Ruschka; Andronikou, Savvas; Beningfield, Stephen J; Hatherill, Mark
    INTRODUCTION: The diagnosis of childhood pulmonary tuberculosis (TB) can be notoriously difficult. The chest X-ray (CXR) is a significant diagnostic resource in the detection of PTB in children. However, non-specific radiological features combined with variable inter-observer assessment s contribute to diagnostic uncertainty. The CXR would be of most value when used specifically to evaluate those features of childhood TB that it shows best and where expert observers agree, namely those signs indicating lymphadenopathy. AIM: To identify simple and reliable CXR features of primary TB in children by determining signs and anatomical sites of best observer agreement. METHOD: This is a retrospective descriptive study within a clinical trial performed by the South African TB Vaccine Initiative (SATVI). Healthy BCG-vaccinated newborn infants in a high TB prevalence rural area in Worcester, near Cape Town, South Africa, were followed for a minimum of two years for possible incident al pulmonary TB. Three independent, blinded, expert paediatric radiologists reported the resultant CXR images using a standardised data collection tick sheet, on which the specific anatomical sites and signs of pathology consistent with pulmonary TB were recorded. The first 200 original data collection tick sheets were sampled and recorded in a pre-compiled data spreadsheet for our study. The sampled data were t hen analysed using kappa statistics. RESULTS: The overall combined agreement for airway compression (by presumed lymphadenopathy) was 0.5%. Five % of the CXR's had soft tissue densities reflecting lymphadenopathy on the frontal view and 5% on the lateral view. The most common site reflecting lymphadenopathy through airway narrowing or displacement was the left main bronchus. The hilar region (kappa 0.27) on the frontal CXR and behind bronchus intermedius (kappa 0.18) on the lateral were the most common sites of soft tissue densities reflecting lymphadenopathy. There were no positive findings for cavitation or pleural effusion. The overall decisions reflecting PTB (lymphadenopathy or miliary) by each individual reader were 27.6% by Reader 1, 8.5% by Reader 2 and 24.6 % by Reader 3. Abnormal findings not specific for PTB were found in 3.5 % by Reader 1, 10.5% by Reader 2 and 3.5% by Reader 3.68. 3 % of the radiographs were reported as normal by Reader 1, 81.9% by Reader 2 and 66.8 % by Reader 3. Only 5% of the radiographs were found to be unreadable by one reader. The overall agreement of all three readers on PTB was 14.6 % and for normal CXR 49.2%. CONCLUSIONS: The fair degree of agreement amongst expert readers suggests that the CXR alone is not a reliable tool for detecting pulmonary TB and should be utilised in conjunction with the clinical features and/or skin tests and blood results. Soft tissue masses rather than airway compression are a more reliable sign for lymphadenopathy, with the most agreed upon sites on the frontal projection for soft tissue mass detection being the right hilar region, followed by the left hilum. Unfortunately, this study could not confirm the usefulness of the CXR in subcategorising PTB into severe and non-severe groups due to the absence of any positive features for severe PTB in the selected sample. The use of prescribed tick-sheets with specified features for detecting lymphadenopathy did not have the expected impact of promoting interobserver consensus of CXR findings in children in terms of detection of TB. The absence of a credible reference standard for lymphadenopathy remains a significant limitation.
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    High density exudates and basal meningeal enhancement in computed tomography of the head in the diagnosis of paediatric tuberculous meningitis
    (2005) Andronikou, Savvas
    Includes bibliographical references (leaves 81-86).
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    New imaging approaches for improving diagnosis of childhood tuberculosis
    (Health and Medical Publishing Group, 2014) Bélard, Sabine; Andronikou, Savvas; Pillay, Tanyia; Grobusch, Martin P; Zar, Heather J
    In South Africa (SA), childhood tuberculosis (TB) still accounts for considerable morbidity and mortality. The incidence of TB disease and risk of progression to severe or disseminated forms are especially high in young children or those with HIV infection. Childhood TB presents most commonly as primary TB, often with non specific signs and symptoms; TB may also present as acute pneumonia. The clinical diagnosis can therefore be challenging. Furthermore, due to difficulty in obtaining good-quality specimens and the paucibacillary nature of childhood TB, microbiological confirmation is only achieved in a minority of children, especially in settings where there is limited capacity for microbiological confirmation.
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    Range and frequency of AORTIC arch variants in a South African population
    (2019) Kasirye, Napo Nalunga Sayfa; Andronikou, Savvas; Said-Hartley, Qonita
    The purpose of this study was to describe the range and frequency of aortic arch (AA) branching patterns using multi-detector computed tomography (MDCT). MDCT images of 400 patients who attended Groote Schuur Hospital between January 2013 and December 2014 for CT Chest and CT Thoracic angiogram were assessed. Six different branching patterns were observed. A left-sided AA with three major branches was present in 67% of the patients. Bovine-type AA (26 %) and independent origin of the left vertebral artery (5%) were the next two most common patterns. The pattern and distribution of aortic arch branching patterns demonstrated in our study matches those found in studies conducted in other populations in South Africa, Kenya and other countries around the world. In addition, a link between gender and aortic arch branching patterns has been demonstrated in our study. Knowledge of the presence of variant aortic arch branching patterns will aid interventionists and surgeons to better plan procedures in order to avoid complications. Therefore, performing CT Angiograms of the chest in patients admitted for procedures involving the thorax would be beneficial.
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    The risks of medical imaging: a survey of doctors' knowledge and consenting practice
    (2018) Nair, Tamiya; Andronikou, Savvas
    Background: Diagnostic imaging forms an integral part of patient evaluation and its use has increased dramatically. Not only is medical imaging a source of increased radiation dose, but also poses other risks such as those related to the procedure performed, the contrast and drugs administered, acoustic and heat deposition and para-magnetic risks. While many studies have assessed doctors' knowledge of radiation risk, data regarding doctors' knowledge of the remaining risks of medical imaging and doctors' attitudes toward consenting practice for imaging is lacking. Aim: To survey and compare the levels of knowledge between referring clinicians and radiologists regarding the risks to patients undergoing medical imaging and to explore doctors' attitudes toward consenting practice. Method: A cross sectional, observational, descriptive study design was employed. The study was conducted using a non-validated, piloted, self-administered three-page questionnaire. The questionnaire was distributed to doctors in various stages of their medical careers at a tertiary level hospital. The questionnaire was constructed in sections including demographics, risks of medical imaging and consent practice. The maximum score potentially attainable was 79, with a point given for each correct answer. No points were given for incorrect, unsure or blank responses. Results: A total of 431 questionnaires were distributed but only 85 doctors (19 radiologists and 66 clinicians) returned a completed survey, yielding a response rate of 19,7%. Older respondents with more years of experience had greater levels of knowledge regarding the risks of medical imaging. There were no significant differences according to gender or university. Although the levels of knowledge of risk was poor overall, radiologists had greater levels of knowledge (mean knowledge score expressed as a percentage =79% compared to that of clinicians= 71%). The largest proportion of doctors' (49%) were of the opinion that clinicians should be responsible for obtaining consent for medical imaging. Only 18% of doctors (radiologists and clinicians) and 5% of clinicians admitted to feeling adequately prepared to obtain consent for medical imaging. Conclusion: We successfully surveyed and compared the levels of knowledge of medical imaging risks amongst doctors and determined their attitudes toward responsibility for consent. The levels of knowledge of the risks of medical imaging is inadequate among radiologists and poor amongst non-radiologists. While statutory body guidelines recommend that the performing health care provider obtain consent, there remains varying opinion as to who should obtain consent. The largest proportion of doctors' were of the opinion that clinicians should obtain consent for medical imaging - this despite clinicians' feelings of inadequacy when consenting patients to the risks of imaging. It is therefore important to take into consideration the levels of knowledge and comfort when making decisions as to who is best suited to obtain consent for medical imaging. With the increased dependence on medical imaging as part of the diagnostic work up, awareness of the risks of medical imaging is of tantamount importance. It is essential to review educational curricula and local policies in order to improve the levels of knowledge of risks of medical imaging amongst healthcare providers, thereby ensuring improved patient safety.
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    Value of follow-up CT in head injury assessment
    (2015) Owen, Jeannine Margaret; Andronikou, Savvas
    INTRODUCTION: The question of when and if to perform follow- up CT scanning of the brain in a patient with a proven head injury remains pertinent, and the answer is not clear cut. This is even more so compounded when one tries to compare and equate what happens in a developed country with that of a developing country such as South Africa. AIM: To evaluate referral patterns, associated time-delays and findings of follow-up CT as well as patient outcomes in patients with head injury at Groote Schuur Hospital. METHOD: A retrospective review, over a 6 month time period, of the CT scans and folders belonging to patients who underwent follow-up CT scanning of the brain after blunt trauma to the head. RESULTS: There were 313 follow-up studies performed in 212 patients, of which the majority, 135 /313 (43.1%) were referred for neurological reasons, whilst 103/313 (32.9%) were referred for conservative management reasons and 75/313 (24%) were referred as part of their post-surgical check-up. There were significant time delays from arrival of patients in casualty to their initial CT scan (mean 18.74 hours) as well as between the initial CT and the first follow-up scan (mean 121.78 hours). There was a significant amount of data missing regarding the time of actual injury for many patients. There were 74 neurosurgical interventions that took place as a result of CT scans performed. Of these, 54 (73%) took place after the initial CT scan, whilst only 20 (27%) occurred after a follow-up CT. Of those surgical interventions performed after a follow- up study, 6 (30%) were performed as a result of a scan performed for post-surgical check- up. 12 (60%) were performed as a result of a scan performed for neurological reasons. Two (10%) neurosurgical interventions occurred as a result of a scan performed for conservative management reasons (thus routine follow-up imaging). CONCLUSIONS: A routine single follow-up CT may be a reasonable approach with further follow-up imaging reserved for patients who have undergone surgery, those with possibly surgically manageable findings on initial CT (that do not undergo surgery) and those with new neurology. The routine use of follow-up CT beyond the first follow-up CT is unlikely to lead to a change in management when the above clinical, and prior CT findings are absent. However, the time delays across all aspects of imaging traumatic brain injuries in our setting are unpredictable and represent a major problem in standardising when CT scans are performed.