Browsing by Author "Beningfield, Steve"

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    A Straight Left Heart Border: A New Radiological Sign of a Hemopericardium
    (2014) Nicol, Andrew John; Navsaria, Pradeep Harkison; Beningfield, Steve; Kahn, Delawir
    Background: Detection of a cardiac injury in a stable patient after a penetrating chest injury can be difficult. Ultrasound of the pericardial sac may be associated with a false negative result in the presence of a hemothorax. A filling in of the left heart border inferior to the pulmonary artery, called the straight left heart border (SLHB), is a radiological sign on chest X-ray that we have found to be associated with the finding of a hemopericardium at surgery. The aim of the present study was to determine if this was a reliable and reproducible sign. Methods: This was a prospective study of patients with a penetrating chest injury admitted between 1 October 2001 and 28 February 2009, who had no indication for immediate surgery, and were taken to the operating room for creation of a subxiphoid pericardial window (SPW). The chest X-ray was reviewed by a single trauma surgeon prior to surgery. Results: A total of 162 patients with a possible occult cardiac injury underwent creation of a SPW. Fifty-five of the 162 patients (34 %) were noted to have a SLHB on chest X-ray and a hemopericardium confirmed at SPW. The sensitivity of the SLHB sign was 40 %; specificity, 84 %; and positive predictive value, 89 %. (p = 0.005, Odds ratio 3.48, lower 1.41, upper 8.62). Conclusions: The straight left heart border is a newly described radiological sign that was highly significant in predicting the presence of a hemopericardium and should alert the clinician to a possible occult cardiac injury.
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    An analysis of prognostic, endoscopic and transjugular intrahepatic portosystemic salvage shunting factors influencing rebleeding and death in portal hypertensive patients with life-threatening variceal bleeding
    (2025) Krige, Jacobus; Jonas, Eduard; Beningfield, Steve
    The management of refractory variceal bleeding constitutes one of the most difficult and complex life-threatening emergencies in surgical gastroenterology. Over the past four decades the treatment of variceal bleeding has evolved and improved with the consequence that mortality has decreased substantially to current rates of 15 to 20% at six weeks after the index variceal bleed. Significant advances have included new vasoactive drug combinations, improved endoscopic techniques with refinements in variceal ligation equipment using multi-band devices and the selective use of radiologically inserted transjugular intrahepatic portosystemic shunts (TIPS). While medical and endoscopic technical advances in treatment have reduced overall mortality, uncontrolled, recurrent and persistent refractory bleeding from recalcitrant varices and the consequences of progressive liver failure remain the leading causes of early death in portal hypertensive patients. Despite progress in overall management, specific limitations in treatment and deficiencies in existing knowledge remain and represent areas where further research, analysis and clinical improvements are necessary. These investigations relate to the need for more accurate prognostic scoring in complex variceal bleeding, the lack of comparative efficacy outcome data for injection sclerotherapy and endoscopic ligation when treating active variceal bleeding, the long-term limitations of endoscopic ligation in eradicating varices, preventing variceal recurrence and rebleeding and crucially, improving the safety profile of variceal interventional endoscopy. In addition, there is a dearth of clinical and laboratory risk factors predicting in-hospital mortality and intermediate and long-term survival after salvage transjugular intrahepatic portosystemic shunting when used as a rescue method in patients who have endoscopically uncontrolled variceal bleeding. These major clinical issues and deficiencies are addressed in this thesis which comprises a literature review and six clinical investigations. A. The literature review component focusses on three main variceal bleeding themes. These include: 1. Prognostic predictors of mortality in acute variceal bleeding including a comparative evaluation of existing Child-Pugh and MELD scores, the pathophysiology of variceal bleeding and the implications of altered oesophageal venous anatomy on endoscopic treatment of varices. 2. Endoscopic methods used in acute variceal bleeding including a historical perspective and the evolution of endoscopic variceal intervention, injection sclerotherapy and variceal ligation endoscopic techniques, and comparative studies evaluating the relative efficacies of endoscopic variceal intervention in the treatment of acute variceal bleeding and an analysis of oesophageal, regional and systemic adverse events after endoscopic variceal ligation for oesophageal varices. 3. A review of salvage transjugular intrahepatic portosystemic shunts (sTIPS) for uncontrolled oesophageal variceal bleeding, including a historical background, the evolution and development of sTIPS, indications and insertion technique, contra-indications and complications of TIPS insertion, and the results of sTIPS. B. An assessment of the major unresolved clinical variceal bleeding-related issues indicated above are addressed in six clinical investigations which constitute the research component of this thesis. 1. Improvement of prognostic scoring: While the ideal prognostic score should be accurate, objective, functional on a continuous scale, validated worldwide, be able to guide treatment and easy to calculate, the currently available Child-Pugh and MELD scores are flawed when used to assess severity of liver dysfunction and predict patient risk for in-hospital rebleeding and death. Neither score is ideal, and both have intrinsic limitations related to their development and inclusion of biochemical and clinical components. Study 1 in this thesis addresses these issues and proposes and validates a new 4-category recalibrated C-P score. 2. Endoscopic control of acute variceal bleeding. Immediate and durable endoscopic control of acute variceal bleeding is the objective of intervention and is crucial to survival. Study 2 in this thesis evaluated the relative efficacies of endoscopic ligation and injection sclerotherapy in arresting acute variceal bleeding in a matched controlled cohort study. 3. Determining the benefits and limitations of endoscopic banding in variceal bleeding. Although the utility of endoscopic therapy in controlling acute variceal bleeding has been widely reported, the long-term efficacy and safety of banding in a high-risk cohort of patients with active variceal bleeding is poorly defined and documented. Study 3 in this thesis assessed acute bleeding control, rebleeding, variceal eradication and recurrence after endoscopic banding in a prospective longitudinal observational study. 4. Identifying factors influencing in-hospital mortality for salvage TIPS in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention. TIPS is now established as the preferred rescue or salvage procedure for patients who have either uncontrolled or severe recurrent variceal bleeding unresponsive to medical and endoscopic treatment. Study 4 in this thesis investigated the outcome of sTIPS in patients who had life-threatening variceal bleeding resistant to standard treatments in order to identify clinical and laboratory risk factors that would predict in-hospital death during the index admission. 5. Intermediate and long-term outcomes after salvage TIPS for uncontrolled variceal bleeding. The reported long-term survival data after salvage TIPS placement are widely divergent due to differing inclusion criteria, population selection, timing of TIPS, severity of underlying liver disease and the experience of the faculty and the facility in the management of critically ill patients with end-stage liver disease. Accurate patient selection is an important consideration in the TIPS procedure. Study 5 in this thesis assessed intermediate and long-term survival after sTIPS to identify possible prognostic factors influencing prolonged survival. 6. Development of a novel CABIN prognostic score to predict in-hospital mortality After salvage TIPS and testing the efficacy of the new score against other established prognostic models. Several prognostic and risk scores have been developed to identify patients at risk for a poor clinical outcome after sTIPS insertion. Although these individual models have been correlated with TIPS outcome, their relative performances have not been assessed in a detailed analysis. Study 6 in this thesis assessed the accuracy of a newly developed and novel CABIN score and compared the CABIN score to existing established risk scores to predict in-hospital mortality after sTIPS placement. The studies reported in this thesis are original, relevant and important and make a substantial contribution to the existing body of knowledge. As the six studies are clinically based and involve portal hypertensive patients with acute and life-threatening variceal bleeding which has a substantial mortality rate, any improvement in outcome will have a beneficial impact on existing patient care. The newly proposed 4-category recalibrated Child-Pugh score is easy to calculate at the bedside and can assist in guiding treatment and predicting the risk of in-hospital variceal rebleeding and death. In the matched controlled cohort study, endoscopic ligation has been shown to be the optimal method of controlling acute variceal bleeding, while the long-term study defined the benefits and exposed the limitations of variceal ligation. The three salvage TIPS studies identified factors influencing in-hospital mortality in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention, as well as intermediate and long-term outcomes and predictive risk factors. The development of a novel CABIN prognostic score designed to predict in-hospital mortality after salvage TIPS was shown to be an improvement over other established prognostic models and should be beneficial in future accurate patient selection for salvage TIPS. In making recommendations for future research, new prognostic scoring systems incorporating artificial intelligence, machine learning algorithms and neural network models will need to be assessed and included as part of essential variceal bleeding clinical algorithms. Because published results are variable and conflicting with small sample sizes, referral bias, dissimilar study endpoints, differences in patient selection, methods and techniques of endoscopic intervention and the precise definition of rebleeding, specific and uniformly defined study end-points are required. Unexplored research areas of quality of life and cost-effective issues are increasingly important concepts to consider in future trial design. As endoscopic failure to control variceal bleeding is encountered by even the most experienced endoscopists, the clear definition and early recognition of endoscopic failures and the implementation of local control methods including self-expanding oesophageal metal stents and improved quality PTFE-coated TIPS stenting are anticipated to improve bleeding control and survival in this high-risk cohort. Several important and unresolved issues relating to the specific role of sTIPS in the management of patients with actively bleeding uncontrolled oesophageal varices remain. Published results are variable and conflicting and an important future goal will be to define and identify the specific target population who would benefit or not from sTIPS. Another objective which requires further investigative research is accurately identifying stable but recurrent variceal bleeders who would benefit from pre-emptive or early-TIPS. The literature review in this thesis has shown considerable variation in the quality of randomised trials evaluated, especially regarding generation of allocation sequences and allocation concealment adversely affecting patient selection, assessment and attrition bias. Despite the number of concluded studies, there remain unresolved questions. Understanding the problems inherent in the design, execution and interpretation of clinical trials in portal hypertension is critical to eliminating quality variations by addressing these deficiencies and answering these questions when planning future studies. In addition, the statistical power of trials remains a major problem in portal hypertension trials, where modest survival advantages are unlikely to be detected unless large-scale, multicentre randomised trials are undertaken incorporating sufficient patient numbers. A further limitation is that only a modest number of published trials have performed blinded outcome assessment. The implications for future research into variceal bleeding are that adequately powered, meticulously conducted, properly reported multicentre trials need to continue to address unresolved issues. As patient recruitment becomes an increasing impediment, future studies require internationally accepted standard protocols to facilitate aggregated analyses and future meta-analyses. In addition, the increasing demand for medical fiscal discipline and logistic efficiency require the issue of cost to be adequately addressed in prospective studies, as illustrated by concerns raised at the recent Baveno Consensus Conferences on future improvements and research requirements in portal hypertension (de Franchis, 2024).
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    Evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the Cape Town Metropole West region
    (2018) Vorster, Isak Dawid; Beningfield, Steve; Bruijns, Stevan
    Introduction: The immediate response to a cardiac arrest is regarded as one of the most time-critical interventions in clinical medicine. First responders for cardiac arrest in imaging departments are often radiology staff. The study aim was to determine radiology staff-members' confidence in initiating basic life support. Methods: A multi-centre, cross-sectional survey was conducted using peer-validated, anonymous questionnaires. Confidences were recorded using a 10-point Likert scale for recognising cardiac arrest, securing an airway, providing rescue breaths and initiating cardiac compressions. Questionnaires were distributed to and completed by radiology staff working in public sector hospitals within the Cape Town Metropole West. Due to the limited subject pool a convenience sample was collected (with no power calculation). Data were therefore statistically analysed using only summary statistics (mean, standard deviation (SD), proportions, etc.). Detailed between group comparisons were not made, given the sample size and type. Results: We disseminated 200 questionnaires, of which 74 were completed (37%). There were no incomplete questionnaires or exclusions from the final sample. Using the Likert scale, the mean ability to recognise cardiac arrest was 6.45 (SD±2.7), securing an airway 4.86 (SD±2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (SD±2.9). Only 2 (2.7%) of the participants had completed a basic life support course in the past year, while 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any type of life support or critical care course. Radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups. Conclusion: The study demonstrates substantial lack of confidence in providing basic life support in a large part of the staff in Cape Town’s public hospital imaging departments. The participants indicated that regular training and improved support systems would increase confidence levels and improve skills.
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    Feasibility of using LODOX technology for mammography
    (2001) Lease, Alyson; Vaughan, Christopher Leonard (Kit); Beningfield, Steve
    Bibliography: leaves 94-99.
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    ISR Congress: Cape Town 2006
    (2006) Beningfield, Steve
    So the International Society of Radiology Congress blew through the Foreshore like the South-Easter – hopefully it went well for you? After the lead-up of years of preparation and planning, the actual event passed in a flash. What with the multiple tracks, many outstanding speakers, the generous exhibitor’s displays and catching up with the Diaspora, we were truly spoilt for choice. Speaking of which, it is really gratifying to see what top-quality exports the country’s graduates make – maybe too good!
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    The HPBASA inaugural meeting
    (2006) Beningfield, Steve
    From Friday 13th to Sunday 15th October this year, the inaugural meeting of the Hepato-Pancreatico-Biliary Association of South African (HPBASA) was held in the Sandton Convention Centre. Organised by Professor Martin Smith and Dr Jose Ramos on behalf of the founding committee, this meeting was decidedly not dominated by any group, but was rather specifically meant as a multidisciplinary gathering of those interested in liver and pancreatic disease. Radiology was represented by a number of our group, as were radiation oncologists, nuclear medicine physicians, surgeons, physicians, anaesthetists, the medical funders and the ultimate arbiters, the pathologists. Regrettably, one of the liver pathology pioneers, Professor Pauline Hall, was unable to be present.