Bartter Syndrome Presenting as Arginine-Vasopressin Resistance: A Report of 2 Cases.

BACKGROUND Bartter syndrome is a rare, inherited salt-wasting tubulopathy caused by mutations in 1 of 6 genes that express ion transport channels in the thick ascending limb of nephrons. Excessive prostaglandin E2 and associated hyperreninemic hyperaldosteronism occurs, causing polyhydramnios, polyuria, prematurity, failure to thrive, and characteristic physical features. Hypokalemia, hypochloremic metabolic alkalosis, and, depending on the affected gene, hypercalciuria and nephrocalcinosis are hallmarks of Bartter syndrome. CASE REPORT A 9-month-old male infant, born prematurely due to polyhydramnios, presented in the Emergency Department with dehydration due to incoercible vomiting and significant polyuria. A 6-year-old male infant with a previous history of prematurity due to polyhydramnios was referred to the Pediatric Endocrinology Department due to short stature and notable polydipsia and polyuria. Considering these marked symptoms, both cases triggered suspicion and started workup for arginine-vasopressin insufficiency/resistance. However, during the investigations, a broader clinical revision revealed that both had dysmorphic physical features (triangularly shaped face, prominent forehead, protruding ears, drooping mouth), poor growth, impaired weight gain, and typical biochemical findings (hypokalemic metabolic alkalosis, hypercalciuria, secondary hyperaldosteronism) of Bartter syndrome. Genetic testing confirmed the diagnosis of Bartter syndrome types 1 and type 2, respectively, and this diagnosis allowed proper treatment and significant clinical improvements, personalized follow-up, and genetic counseling for parents desiring further healthy pregnancies. CONCLUSIONS Here, we present clinical and follow-up findings of 2 patients with Bartter syndrome types 1 and 2 discovered upon a broader clinical revision of suspected arginine-vasopressin insufficiency/resistance. We also review pertinent data on diagnosis and management of this challenging syndrome.

An Approach to Establishing Diagnostic Reference Levels in Interventional Pediatric Cardiology from Different Regions of Brazil.

Diagnostic reference levels (DRLs) are a pivotal strategy to be implemented since pediatric interventional cardiology procedures are increasing. This work aimed to propose an initial set of Brazilian DRLs for pediatric interventional diagnostic and therapeutic (D&T) procedures. A retrospective study was carried out in four Brazilian states, distributed across the three regions of the country. Data were collected from pediatric patients undergoing cardiac interventional procedures (CIPs), including their age and anthropometric characteristics, and at least four parameters (number of images, exposure time, air kerma-area product-PKA, and cumulative air kerma). Data from 279 patients undergoing CIPs were gathered (147 diagnostic and 132 therapeutic procedures). There were no significant differences in exposure time and the number of images between the D&T procedures. A wide range of PKA was observed when the therapeutic procedures were compared to diagnostics for all age groups. There were significant differences between the D&T procedures, whether grouping data by patient weight or age. In terms of cumulative air kerma, it was noted that no value exceeded the level to trigger a monitoring process for patients. This study shows that it is possible to adopt them as the first proposal to establish national DRLs considering pediatric patient groups.

Cardiologist's exposure to radiation in cath lab measured with InstadoseTMdosimeter.

INTRODUCTION: complex fluoroscopy-guided interventional procedures in cardiology are known to result in higher radiation doses for patients and staff. PURPOSE: to estimate the equivalent dose received in different regions of the cardiologist's body in catheterism (CATH) and percutaneous coronary intervention (PCI) procedures, as well as to evaluate the effectiveness of monitoring the doses in the catheritization laboratory (cath lab) using a direct ion storage dosimeter. MATERIALS AND METHODS: the InstadoseTMand the thermoluminescent dosimeters (TLD-100) were fixed simultaneously in the following regions of the cardiologist's body: near the eyes (left and right), the trunk region (over the lead apron) and the left ankle. Occupational doses were recorded during 86 procedures (60% CATH). RESULTS: catheterization procedures showed third quartile dose values near to the left eye region equal to 0.10 mSv (TLD-100) and 0.12 (InstadoseTM) and for intervention 0.15 mSv (TLD-100 and InstadoseTM). The doses measured in the trunk region, over the lead apron, were about 13% higher for catheterization procedures and 20% higher for intervention procedures compared to left eye region measurements. The Wilcoxon-Mann-Whitney test was applied for unpaired data for all body regions, comparing the data obtained between the TLD-100 and InstadoseTMdosimeters. For CATH and PCI, the responses of the TLD-100 and InstadoseTMdosimeters are considered equal for all analysed regions (p> 0.05) with the exception of the right eye region. CONCLUSION: the InstadoseTMpassive dosimeter can be useful as a complementary assessment in the monitoring of a cardiologist's personal occupational doses in the cath lab.

Assessing trauma readiness costs in level III and level IV trauma centers.

BACKGROUND: Readiness costs are expenses incurred by trauma centers to maintain essential infrastructure. Although the components for readiness are described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient , the cost associated with each component is not well defined. Previous studies describe readiness costs for levels I and II trauma centers based on these criteria. The purpose of this study was to quantify the cost of levels III and IV trauma center readiness. METHODS: The state trauma commission, along with trauma medical directors, program managers, and trauma center financial staff, standardized definitions for each component of trauma center readiness costs and developed a survey tool for reporting. Readiness costs were grouped into four categories: Administrative/Program Support Staff, Clinical Medical Staff, and Education/Outreach. A financial auditor analyzed all data to verify consistent cost reporting. Trauma center outliers were evaluated to validate variances. All levels III and IV trauma centers (n = 14) completed the survey on 2019 data. RESULTS: Average annual readiness cost is $1,715,025 for a level III trauma center and $81,620 for level IV centers. Among the costliest components were clinical medical staff for level IIIs and administrative costs for level IVs, representing 54% and 97% of costs, respectively. Although education/outreach is mandated, levels III and IV trauma centers only spend approximately $8,000 annually on this category (0.8-3%). CONCLUSION: This study defines the cost associated with each readiness component outlined in the Resources for Optimal Care of the Injured Patient manual. The average readiness cost for a level III trauma center is $1,715,025 and $81,620 for a level IV, underscoring the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and Value-Based Evaluations; Level III.

Needs Based Assessment of Trauma Systems 2, is it ready for primetime? A natural experiment testing its reliability.

INTRODUCTION: Needs Based Assessment of Trauma Systems 2 (NBATS-2) attempts to predict the impact on patient volume and travel time for patients when a new trauma center (TC) is added to the system. The purpose of this study was to examine NBATS-2 predictive accuracy regarding expected volume and travel times of trauma patients at a newly designated TC and nearby legacy TCs when compared with actual data. METHODS: Needs Based Assessment of Trauma Systems predictive model for volume of trauma patients at the new TC was run based on 25th, 50th, and 75th percentiles of both state and National Trauma Data Bank (NTDB) patients per 100 TC beds. This was compared with the actual number of trauma patients from the State Discharge Data set before (2011-2012) and after (2016-2017) designation of the TC. Analysis was then augmented using the geographic information system (ArcGIS) spatial modeling to characterize median travel times for actual trauma patients, before and after designation of the TC. RESULTS: Both state and NTDB 25th, 50th, and 75th percentiles resulted in significant overestimation of volume at the new TC in 2016. After another year of TC maturation (2017), overestimation decreased but was still present. The 25th percentile from state and NTDB data sets provided the most accurate predictions. For the legacy TCs, the model switched from under to overestimation as the state and NTDB percentiles increased. The geographic information system accurately showed patients traveling <40 minutes to a TC nearly doubled. CONCLUSION: Needs Based Assessment of Trauma Systems 2 provides an excellent template for state strategic planning; however, it overestimates new TC volume and under/overestimates volumes for legacy TCs depending on the state and NTDB percentiles used. This study shows that population density of the county in which the new or legacy TC is located should be considered when choosing the appropriate state or NTDB percentile. The geographic information system appropriately showed a decrease in trauma patient travel times after TC designation. LEVEL OF EVIDENCE: Care Management, level V.

An overview of acquisition parameters, dose measurements and organ doses in abdominal CT scans in Brazil.

The aim of this multi-centre study was to evaluate the irradiation parameters and the radiation dose of abdomen CT exams without contrast, performed in adults In Brazil, in order to provide an overview of the CT installed base in the country and contribute for the establishment of optimization programs. Equipment of seven different models, with 16 and 64 channels, installed in 17 Brazilian states, plus the Federal District, were analyzed. The results show that the mean CTDIvol ranged from 6.60 mGy to 34.64 mGy. The results also showed that different irradiation parameters are used in equipment of the same model, resulting, in some cases, in three times higher CTDIvol values. These characteristics are not restricted to a given region of the country but distributed throughout the national territory. Repetitions of acquisitions and topograms with scan length larger than the region of interest were found in 13.5% of abdomen examinations, resulting in considerably higher absorbed doses than expected. This survey of the abdomen tomography exams, performed in about 74% of the Brazilian states, showed that in many clinics the procedures are not optimized. This study can be used for the planning of dose optimization programs and will contribute to the establishment of local diagnostic reference levels (DRL) for CT.

Accelerated Biologic Aging, Chronic Stress, and Risk for Sepsis and Organ Failure Following Trauma.

Chronic stress and accelerated aging have been shown to impact the inflammatory response and related outcomes like sepsis and organ failure, but data are lacking in the trauma literature. The purpose of this study was to investigate potential relationships between pretrauma stress and posttrauma outcomes. The hypothesis was that pretrauma chronic stress accelerates aging, which increases susceptibility to posttrauma sepsis and organ failure. In this prospective, correlational study, chronic stress and accelerated biologic aging were compared to the occurrence of systemic inflammatory response syndrome, sepsis, and organ failure in trauma patients aged 18-44 years. Results supported the hypothesis with significant overall associations between susceptibility to sepsis and accelerated biologic aging (n = 142). There were also significant negative associations between mean cytokine levels and chronic stress. The strongest association was found between mean interleukin-1ß (IL-1ß) and human telomerase reverse transcriptase (hTERT), r(101) = -0.28), p = .004. Significant negative associations were found between mean cytokine levels, IL-12p70, r(108) = -0.20, p = .034; and tumor necrosis factor-α (TNF-α), r(108) = -0.20, p = .033, and positive life events via the behavioral measure of chronic stress. Results may help identify individuals at increased risk for poor outcomes of trauma and inform interventions that may reduce the risk for sepsis and organ failure.

Characterization of the imaging settings in screening mammography using a tracking and reporting system: A multi-center and multi-vendor analysis.

A tracking and reporting system was developed to monitor radiation dose in X-ray breast imaging. We used our tracking system to characterize and compare the mammographic practices of five breast imaging centers located in the United States and Brazil. Clinical data were acquired using eight mammography systems comprising three modalities: computed radiography (CR), full-field digital mammography (FFDM), and digital breast tomosynthesis (DBT). Our database consists of metadata extracted from 334,234 images. We analyzed distributions and correlations of compressed breast thickness (CBT), compression force, target-filter combinations, X-ray tube voltage, and average glandular dose (AGD). AGD reference curves were calculated based on AGD distributions as a function of CBT. These curves represent an AGD reference for a particular population and system. Differences in AGD and imaging settings were attributed to a combination of factors, such as improvements in technology, imaging protocol, and patient demographics. The tracking system allows the comparison of various imaging settings used in screening mammography, as well as the tracking of patient- and population-specific breast data collected from different populations.

Prevalence of Lens Opacity in Interventional Cardiologists and Professional Working in the Hemodynamics in Brazil / Prevalência de Opacidades do Cristalino em Cardiologistas Intervencionistas e Profissionais Atuantes na Área de Hemodinâmica no Brasil

Abstract Background: Posterior subcapsular cataract is a tissue reaction commonly found among professionals exposed to ionizing radiation. Objective: To assess the prevalence of cataract in professionals working in hemodynamics in Brazil. Methods: Professionals exposed to ionizing radiation (group 1, G1) underwent slit lamp examination with a biomicroscope for lens examination and compared with non-exposed subjects (group 2, G2). Ophthalmologic findings were described and classified by opacity degree and localization using the Lens Opacities Classification System III. Both groups answered a questionnaire on work and health conditions to investigate the presence of risk factors for cataract. The level of significance was set at 5% (p < 0.05). Results: A total of 112 volunteers of G1, mean age of 44.95 (±10.23) years, and 88 volunteers of G2, mean age of 48.07 (±12.18) years were evaluated; 75.2% of G1 and 85.2% of G2 were physicians. Statistical analysis between G1 and G2 showed a prevalence of posterior subcapsular cataract of 13% and 2% in G1 and G2, respectively (0.0081). Considering physicians only, 38% of G1 and 15% of G2 had cataract, with the prevalence of posterior subcapsular cataract of 13% and 3%, respectively (p = 0.0176). Among non-physicians, no difference was found in the prevalence of cataract (by types). Conclusions: Cataract was more prevalent in professionals exposed to ionizing radiation, with posterior subcapsular cataract the most frequent finding.

Resumo Fundamento: A catarata subcapsular posterior é uma reação tecidual encontrada com frequência nos profissionais expostos à radiação ionizante. Objetivo: Avaliar a prevalência de catarata nos profissionais que atuam na área de hemodinâmica no Brasil. Métodos: Profissionais expostos à radiação ionizante (grupo 1, G1) foram submetidos ao exame biomicroscópico com lâmpada de fenda para avaliação do cristalino, e comparados aos não expostos (grupo 2, G2). Os achados foram descritos e classificados quanto ao grau de opacidade e localização por meio do Lens opacities classification system III. Ambos os grupos responderam questionário sobre condições de trabalho e de saúde para afastar fatores de risco para catarata, e foram comparados quanto aos achados. Foi utilizado um nível de significância de 5% (p < 0,05). Resultados: Foram avaliados 112 voluntários (G1) com média de idade 44,95 (±10,23) anos e 88 voluntários (G2) com média de 48,07 (±12,18) anos. Desses, 75,2% (G1) e 85,2% (G2) eram médicos. A análise estatística entre os grupos G1 e G2 mostrou uma prevalência da catarata no grupo G1 de 33% comparada ao G2 de 16% (p = 0,0058), sendo a catarata subcapsular posterior presente em 13% no G1 e 2% no G2 (p = 0,0081). Considerando apenas os médicos, 38% no G1 e 15% no G2 (p = 0,0011) apresentaram catarata, sendo a subcapsular posterior 13% e 3% (p = 0,0176), respectivamente. No grupo dos profissionais não médicos, não houve diferença estatisticamente significativa na prevalência dos achados oftalmológicos. Conclusões: A catarata esteve mais presente no grupo de profissionais expostos à radiação ionizante, sendo que a catarata subcapsular posterior foi o dano tecidual mais encontrado.

Prevalence of Lens Opacity in Interventional Cardiologists and Professional Working in the Hemodynamics in Brazil.

BACKGROUND: Posterior subcapsular cataract is a tissue reaction commonly found among professionals exposed to ionizing radiation. OBJECTIVE: To assess the prevalence of cataract in professionals working in hemodynamics in Brazil. METHODS: Professionals exposed to ionizing radiation (group 1, G1) underwent slit lamp examination with a biomicroscope for lens examination and compared with non-exposed subjects (group 2, G2). Ophthalmologic findings were described and classified by opacity degree and localization using the Lens Opacities Classification System III. Both groups answered a questionnaire on work and health conditions to investigate the presence of risk factors for cataract. The level of significance was set at 5% (p < 0.05). RESULTS: A total of 112 volunteers of G1, mean age of 44.95 (±10.23) years, and 88 volunteers of G2, mean age of 48.07 (±12.18) years were evaluated; 75.2% of G1 and 85.2% of G2 were physicians. Statistical analysis between G1 and G2 showed a prevalence of posterior subcapsular cataract of 13% and 2% in G1 and G2, respectively (0.0081). Considering physicians only, 38% of G1 and 15% of G2 had cataract, with the prevalence of posterior subcapsular cataract of 13% and 3%, respectively (p = 0.0176). Among non-physicians, no difference was found in the prevalence of cataract (by types). CONCLUSIONS: Cataract was more prevalent in professionals exposed to ionizing radiation, with posterior subcapsular cataract the most frequent finding.

How much green does it take to be orange? Determining the cost associated with trauma center readiness.

BACKGROUND: Readiness costs are real expenses incurred by trauma centers to maintain essential infrastructure to provide emergent services on a 24/7 basis. Although the components for readiness are well described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient, the cost associated with each component is not well defined. We hypothesized that meeting the requirements of the 2014 Resources for Optimal Care of the Injured Patient would result in significant costs for trauma centers. METHODS: The state trauma commission in conjunction with trauma medical directors, program managers, and financial officers of each trauma center standardized definitions for each component of trauma center readiness cost and developed a survey tool for reporting. Readiness costs were grouped into four categories: administrative/program support staff, clinical medical staff, in-house operating room, and education/outreach. To verify consistent cost reporting, a financial auditor analyzed all data. Trauma center outliers were further evaluated to validate variances. All level I/level II trauma centers (n = 16) completed the survey on 2016 data. RESULTS: Average annual readiness cost is US $10,078,506 for a level I trauma center and US $4,925,103 for level IIs. Clinical medical staff was the costliest component representing 55% of costs for level Is and 64% for level IIs. Although education/outreach is mandated, levels I and II trauma centers only spend approximately US $100,000 annually on this category (1%-2%), demonstrating a lack of resources. CONCLUSION: This study defines the cost associated with each component of readiness as defined in the Resources for Optimal Care of the Injured Patient manual. Average readiness cost for a level I trauma center is US $10,078,506 and US $4,925,103 for a level II. The significant cost of trauma center readiness highlights the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and value-based evaluations, level III.

Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool.

BACKGROUND: The American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS). METHODS: Population counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15. RESULTS: The Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology. DISCUSSION: The tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services. LEVEL OF EVIDENCE: Economic, level IV.

Implementation of a Massive Transfusion Protocol: Evaluation of Its Use and Efficacy.

Massive transfusion protocols (MTPs) allow practitioners to follow a prescribed algorithm for the rapid replacement of blood products during a massive hemorrhage. They function as an established protocol to provide consistent treatment. Once implemented, the MTP must be evaluated to ensure best practice. The purpose of this clinical improvement project was to formally evaluate the use and efficacy of an MTP during its first year of implementation. The specific aims were to (1) determine whether MTP activations were missed; (2) compare outcomes between those patients managed by the MTP and those who were not; and (3) provide recommendations to the institution's stakeholders. A retrospective medical record review was conducted with 101 electronic medical records of adult trauma patients treated over 1 year. Patients were identified to have experienced massive bleeding if their medical record contained 1 of 4 indicators: (1) transfusion of uncrossmatched blood; (2) tranexamic acid administration; (3) transfusion of 4 or more units of packed red blood cells (PRBCs) in 1 hr; and/or (4) transfusion of 10 or more units of PRBCs in 24 hr. While 58 patients experienced massive bleeding, only 16 (28%) were managed using the MTP. Although the non-MTP group received fewer transfused blood products due to higher initial and 24-hr hemoglobin levels, more deaths occurred in this group than in the MTP group. The recommendations were to (1) establish well-defined criteria for MTP activation based on the 4 indicators of massive bleeding and (2) regularly evaluate the use and efficacy of the MTP to ensure positive patient outcomes.

Association between arteriovenous fistulae and hematomas in a dialysis center in the state of Rio Grande do Sul, Southern Brazil

Introduction: Chronic kidney disease (CKD) is characterized by slow, progressive, and irreversible loss of kidney function. CKD has become a serious public health issue because of its increasing morbidity and mortality rates. The present study aimed to investigate factors associated with hematomas caused by arteriovenous fistula (AVF) at a Renal Replacement Therapy Unit in the state of Rio Grande do Sul, southern Brazil. Methods: In this cross-sectional study, 72 patients with CKD aged 18 years or over, presenting with AVF, and undergoing three hemodialysis sessions per week were evaluated from June 2014 to March 2015. Prevalence ratios (PRs) with 95% confidence intervals (95% CIs) were estimated for identification of risk factors associated with AVF. P-values < 0.05 were considered significant. Results: Sex, age, self-reported skin color, educational level, hypertension, diabetes, nephrotic syndrome, congestive heart failure, and hepatitis C were not associated with hematoma formation (i.e., all estimated PRs had p-values > 0.05). The single factor associated with hematomas was AVF time shorter than 60 days (PR = 2.04; 95% CI: 1.28-3.27; p < 0.01). Conclusion: AVF maturation time was associated with higher prevalence of hematomas at the cannulation site. Therefore, AVF time should be given special attention in patients undergoing renal therapy at dialysis centers. (AU)

Descriptive Analysis of Venous Thromboembolism in Georgia Trauma Centers Compared with National Trauma Centers Participating in the Trauma Quality Improvement Program.

This study was designed to compare the incidence of venous thromboembolism (VTE) in Georgia trauma centers with other national trauma centers participating in the Trauma Quality Improvement Program (TQIP). The use of chemoprophylaxis and characteristics of patients who developed VTE were also examined. We conducted a retrospective observational study of 325,703 trauma admissions to 245 trauma centers from 2013 to 2014. Patient demographics, rate of VTE, as well as the use, type, and timing of chemoprophylaxis were compared between patients admitted to Georgia and non-Georgia trauma centers. The rate of VTE in Georgia trauma centers was 1.9 per cent compared with 2.1 per cent in other national trauma centers. Overall, 49.6 per cent of Georgia patients and 45.5 per cent of patients in other trauma centers had documented chemoprophylaxis. Low molecular weight heparin was the most commonly used medication. Most patients who developed VTE did so despite receiving prophylaxis. The rate of VTE despite prophylaxis was 3.2 per cent in Georgia and 3.1 per cent in non-Georgia trauma centers. Mortality associated with VTE was higher in Georgia trauma centers compared with national TQIP benchmarks. The incidence of VTE and use of chemoprophylaxis within Georgia trauma centers were similar to national TQIP data. Interestingly, most patients who developed VTE in both populations received VTE prophylaxis. Further research is needed to develop best-practice guidelines for prevention, early detection, and treatment in high-risk populations.

What Are the Costs of Trauma Center Readiness? Defining and Standardizing Readiness Costs for Trauma Centers Statewide.

Trauma center readiness costs are incurred to maintain essential infrastructure and capacity to provide emergent services on a 24/7 basis. These costs are not captured by traditional hospital cost accounting, and no national consensus exists on appropriate definitions for each cost. Therefore, in 2010, stakeholders from all Level I and II trauma centers developed a survey tool standardizing and defining trauma center readiness costs. The survey tool underwent minor revisions to provide further clarity, and the survey was repeated in 2013. The purpose of this study was to provide a follow-up analysis of readiness costs for Georgia's Level I and Level II trauma centers. Using the American College of Surgeons Resources for Optimal Care of the Injured Patient guidelines, four readiness cost categories were identified: Administrative, Clinical Medical Staff, Operating Room, and Education/Outreach. Through conference calls, webinars and face-to-face meetings with financial officers, trauma medical directors, and program managers from all trauma centers, standardized definitions for reporting readiness costs within each category were developed. This resulted in a survey tool for centers to report their individual readiness costs for one year. The total readiness cost for all Level I trauma centers was $34,105,318 (avg $6,821,064) and all Level II trauma centers was $20,998,019 (avg $2,333,113). Methodology to standardize and define readiness costs for all trauma centers within the state was developed. Average costs for Level I and Level II trauma centers were identified. This model may be used to help other states define and standardize their trauma readiness costs.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

Evaluation Tool for Assessing a Newly Implemented Massive Transfusion Protocol.

Exsanguination requires massive blood product replacement and termination of the bleeding source to prevent hemorrhagic shock and death. Massive transfusion protocols (MTPs) are algorithms that allow the health care team to quickly stabilize the bleeding patient and guide blood product administration. However, no national MTP guidelines or a standardized evaluation tool exist for collecting and reporting MTP-related data. The purpose of this article is to describe an original MTP evaluation tool, how it was used, barriers encountered, and a framework for reporting the MTP evaluation data. The evidence-based Broxton MTP Evaluation Tool was developed to evaluate the use of a newly implemented MTP via a retrospective review of electronic medical records (EMRs). Although the instrument itself worked well, barriers were encountered while reviewing the EMRs for the MTP evaluation. These barriers included no institutional entity was charged with tracking MTP activations, no searchable database was established to collect data concerning the MTP-activated patients, and no standard location in the EMR was designated for documenting the MTP activation. When devising protocols such as an MTP, a priori strategies should be developed for its implementation, documentation, and evaluation. Research is needed to determine best practices for evaluating an MTP to ensure positive patient outcomes with this protocol.

Influence of partial k-space filling on the quality of magnetic resonance images.

OBJECTIVE: To study the influence that the scan percentage tool used in partial k-space acquisition has on the quality of images obtained with magnetic resonance imaging equipment. MATERIALS AND METHODS: A Philips 1.5 T magnetic resonance imaging scanner was used in order to obtain phantom images for quality control tests and images of the knee of an adult male. RESULTS: There were no significant variations in the uniformity and signal-to-noise ratios with the phantom images. However, analysis of the high-contrast spatial resolution revealed significant degradation when scan percentages of 70% and 85% were used in the acquisition of T1- and T2-weighted images, respectively. There was significant degradation when a scan percentage of 25% was used in T1- and T2-weighted in vivo images (p ≤ 0.01 for both). CONCLUSION: The use of tools that limit the k-space is not recommended without knowledge of their effect on image quality.

OBJETIVO: Estudar a influência da ferramenta scan percentage, usada para a aquisição parcial do espaço K na qualidade de imagens obtidas por ressonância magnética. MATERIAIS E MÉTODOS: Foi usado um equipamento de ressonância magnética Philips de 1,5 T para obter imagens de um objeto simulador e imagens in vivo do joelho de um adulto do sexo masculino. RESULTADOS: Com o objeto simulador, não ocorreram variações significativas quanto à avaliação da uniformidade e razão sinal-ruído. Entretanto, na análise da resolução espacial de alto contraste, houve significativa degradação nas imagens quando adotada a scan percentage a 70% e 85% em T1 e T2, respectivamente. Nas imagens in vivo comprovou-se a degradação somente quando adotada a scan percentage a 25% (p ≤ 0,01) em T1 e T2. CONCLUSÃO: Não é aconselhável adotar ferramentas que limitem o espaço K sem que haja conhecimento sobre sua influência na qualidade da imagem clinicamente gerada.