Belgian multicentre study on lumbar spine imaging: Radiation dose and cost analysis; Evaluation of compliance with recommendations for efficient use of medical imaging.

PURPOSE: To assess compliance of lumbar spine imaging referrals with national imaging recommendations and to evaluate the impact of inappropriate imaging on the collective radiation dose and health insurance costs. METHOD: In 2011 and 2015, 633 lumbar spine imaging referrals were evaluated across 9 Belgian hospitals. For each patient, a new clinical anamnesis and physical examination were performed. Together with the referral, this data were confronted with the national imaging recommendations. Collective radiation dose was estimated for the radiography and CT procedures. Cost analysis was based on national reimbursement fees. Statistical analysis was performed using multilevel linear and logistic regression models. RESULTS: The fraction of unjustified imaging referrals decreased from 50 % in 2011 to 41 % in 2015 (p = 0.255). The odds of a justified examination are 3.1 times higher when the referral is done by a specialist instead of a general practitioner. The highest percentage of unjustified examinations was found for CT (85 % in 2011, 81 % in 2015; p = 0.044). Seventy-five percent of the collective dose of both the 2011 and the 2015 study population was not justified. Adherence to the recommendations could result in an estimated 16 % and 5 % cost reduction for the 2011 and 2015 study samples, respectively. CONCLUSIONS: Between 2011 and 2015, no significant improvement was found in requesting justified lumbar spine imaging procedures, although a positive trend was observed for CT. A shift from CT to MRI is necessary to improve the appropriateness of lumbar spine imaging referrals and to reduce the collective radiation dose.

The effective and collective dose to patients undergoing abdominopelvic and trunk computed tomography examinations: A Belgian multicentre study.

OBJECTIVES: This study aims to evaluate the radiation exposure to patients undergoing an abdominopelvic or a chest and abdominopelvic (trunk) CT examination and to assess compliance to imaging referral guidelines. METHODS: To this end, 357 standard abdominopelvic and trunk CT scans were collected from 8 Belgian institutions in 2011 and 2015. Effective dose (E) and collective dose were calculated using CT dose descriptors (CTDIvol and DLP), which were obtained from dose reports generated by the CT scanner. Subsequently, these CT requests were compared against the national referral guidelines to assess compliance. Population estimates for dose and compliance were obtained using multilevel linear regression and generalized estimating equation models. RESULTS: Between 2011 and 2015, a significant decrease of 28% in CTDIvol and DLP was found for abdominopelvic CT. The corresponding E decreased by 27%, and the collective dose by 23%. For trunk CT, a non-significant decrease of 6% was found in CTDIvol and a significant decrease of 14% in both DLP and E. However, the collective dose of trunk examinations increased by 39%. In 2011, 24% of the abdominopelvic examinations were not compliant with the guidelines, whereas this percentage dropped to 17% in 2015. Non-justified examinations accounted for 8% and 12% of all trunk CT scans in 2011 and 2015, respectively. CONCLUSION: Between 2011 and 2015, there was a decrease in dose for patients undergoing abdominopelvic or trunk CT in Belgium. However, a fraction of the estimated doses are linked to unnecessary CT examinations, which should be avoided.

Adherence to guidelines for the management of donors after brain death.

PURPOSE: Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD. MATERIALS AND METHODS: This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines. RESULTS: A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set. CONCLUSIONS: Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines.

Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach.

BACKGROUND: A substantial degree of variability in practices exists amongst donor hospitals regarding the donor detection, determination of brain death, application of donor management techniques or achievement of donor management goals. A possible strategy to standardize the donation process and to optimize outcomes could lie in the implementation of a care pathway. The aim of the study was to identify and select a set of relevant key interventions and quality indicators in order to develop a specific care pathway for donation after brain death and to rigorously evaluate its impact. METHODS: A RAND modified three-round Delphi approach was used to build consensus within a single country about potential key interventions and quality indicators identified in existing guidelines, review articles, process flow diagrams and the results of the Organ Donation European Quality System (ODEQUS) project. Comments and additional key interventions and quality indicators, identified in the first round, were evaluated in the following rounds and a subsequent physical meeting. The study was conducted over a 4-month time period in 2016. RESULTS: A multidisciplinary panel of 18 Belgian experts with different relevant backgrounds completed the three Delphi rounds. Out of a total of 80 key interventions assessed throughout the Delphi process, 65 were considered to contribute to the quality of care for the management of a potential donor after brain death; 11 out of 12 quality indicators were validated for relevance and feasibility. Detection of all potential donors after brain death in the intensive care unit and documentation of cause of no donation were rated as the most important quality indicators. CONCLUSIONS: Using a RAND modified Delphi approach, consensus was reached for a set of 65 key interventions and 11 quality indicators for the management of a potential donor after brain death. This set is considered to be applicable in quality improvement programs for the care of potential donors after brain death, while taking into account each country's legislation and regulations regarding organ donation and transplantation.

Direct uptake of canopy rainwater causes turgor-driven growth spurts in the mangrove Avicennia marina.

Mangrove forests depend on a dense structure of sufficiently large trees to fulfil their essential functions as providers of food and wood for animals and people, CO2 sinks and protection from storms. Growth of these forests is known to be dependent on the salinity of soil water, but the influence of foliar uptake of rainwater as a freshwater source, additional to soil water, has hardly been investigated. Under field conditions in Australia, stem diameter variation, sap flow and stem water potential of the grey mangrove (Avicennia marina (Forssk.) Vierh.) were simultaneously measured during alternating dry and rainy periods. We found that sap flow in A. marina was reversed, from canopy to roots, during and shortly after rainfall events. Simultaneously, stem diameters rapidly increased with growth rates up to 70 µm h-1, which is about 25-75 times the normal growth rate reported in temperate trees. A mechanistic tree model was applied to provide evidence that A. marina trees take up water through their leaves, and that this water contributes to turgor-driven stem growth. Our results indicate that direct uptake of freshwater by the canopy during rainfall supports mangrove tree growth and serve as a call to consider this water uptake pathway if we aspire to correctly assess influences of changing rainfall patterns on mangrove tree growth.

Recommendations for further improvement of the deceased organ donation process in Belgium.

Belgium has achieved high deceased organ donation rates but according to the medical record data in the Donor Action database, deceased potential donors are still missed along the pathway. Between 2010 and 2014, 12.9 ± 3.3% of the potential donors after brain death (DBD) and 24.6 ± 1.8% of the potential donors after circulatory (DCD) death were not identified. Conversion rates of 41.7 ± 2.1% for DBD and 7.9 ± 0.9% for DCD indicate room for further improvement. We identify and discuss different issues in the monitoring of donation activities, practices and outcomes; donor pool; legislation on deceased organ donation; registration; financial reimbursement; educational and training programs; donor detection and practice clinical guidance. The overall aim of this position paper, elaborated by a Belgian expert panel, is to provide recommendations for further improvement of the deceased organ donation process up to organ procurement in Belgium.

Care pathways for organ donation after brain death: guidance from available literature?

AIMS: A discussion of the literature concerning the impact of care pathways in the complex and by definition multidisciplinary process of organ donation following brain death. BACKGROUND: Enhancing the quality and safety of organs for transplantation has become a central concern for governmental and professional organizations. At the local hospital level, a donor coordinator can use a range of interventions to improve the donation and procurement process. Care pathways have been proven to represent an effective intervention in several settings for optimizing processes and outcomes. DESIGN: A discussion paper. DATA SOURCES: A systematic review of the Medline, CINAHL, EMBASE and The Cochrane Library databases was conducted for articles published until June 2015, using the keywords donation after brain death and care pathways. Each paper was reviewed to investigate the effects of existing care pathways for donation after brain death. An additional search for unpublished information was conducted. DISCUSSION: Although literature supports care pathways as an effective intervention in several settings, few studies have explored its use and effectiveness for complex care processes such as donation after brain death. IMPLICATIONS FOR NURSING: Nurses should be aware of their role in the donation process. Care pathways have the potential to support them, but their effectiveness has been insufficiently explored. CONCLUSION: Further research should focus on the development and standardization of the clinical content of a care pathway for donation after brain death and the identification of quality indicators. These should be used in a prospective effectiveness assessment of the proposed pathway.

Friday: Fish Day.

A 78-year-old man presented with diffuse abdominal pain, localized peritonitis and raised inflammatory markers. CT revealed an mesentery abcess with a linear high density structure in continuity with the adjacent small bowel lumen. Laparoscopy showed a perforation by a fish bone. Gastrointestinal tract perforation by foreign body ingestion is rare complication (1%). There are some risk factors and prefered locations of perforation. Time interval between ingestion and complication can vary extremely.

Time-dependent changes in 18F-FDG activity in the thymus and bone marrow following combination chemotherapy in paediatric patients with lymphoma.

PURPOSE: To investigate the time-dependent changes in (18)F-FDG uptake by the thymus and marrow following combination chemotherapy for lymphoma in a paediatric study population. METHODS: Included in the study were 27 paediatric patients who were in complete metabolic remission after chemotherapy and who underwent off-therapy follow-up with serial whole-body PET-CT scans. A total of 142 PET-CT scans were recorded. (18)F-FDG uptake by the thymus and marrow was assessed both visually and semiquantitatively. Visual uptake was scored on the three-dimensional maximum intensity projection of the whole-body PET image according to a three-point scale. For the semiquantitative assessment, standard uptake values were measured. To find a pattern in the (18)F-FDG uptake by the thymus and marrow a moving average technique was applied. RESULTS: Our time series analysis indicated that the marrow activity was highest at cessation of chemotherapy and declined thereafter. During an off-chemotherapy period of on average 6 months, marrow activity decreased quickly. From 6 months onward, the activity declined more slowly. The posttherapy changes in (18)F-FDG uptake by the thymus were quite different from the changes in uptake by the marrow. The lowest thymic FDG uptake was found at cessation of chemotherapy. Thereafter, thymic activity steadily increased, reached a peak on average 10 months after therapy, and then slowly decreased. CONCLUSION: Knowledge of the time-dependent changes in metabolic activity in the thymus and marrow is important to avoid misinterpretation of increased (18)F-FDG uptake as disease in the off-therapy setting.

Normal uptake of F-18 FDG in the testis as assessed by PET/CT in a pediatric study population.

OBJECTIVE: To investigate the correlation between the F-18 FDG uptake in the normal testis as assessed by PET-CT and patient age in a pediatric study population. METHODS: The study population consisted of 22 subjects aged between 9 and 17 years. For these subjects 42 PET-CT scans were available for analysis. The testis was identified on the CT images. Mean standard uptake values and testicular volume were calculated based on manually drawn regions-of-interest over the organ. The correlation between mean SUV and age as well as between testicular volume and age was calculated using Pearson's correlation coefficient. RESULTS: A strong and statistically significant positive correlation between F-18 FDG uptake in the testis and age was documented. The correlation coefficient was 0.406 in the analysis based on 42 PET-CT studies (p = 0.005). The correlation between tracer uptake and age was reassessed based on 22 PET-CT studies including the last recorded PET-CT scan per patient. The correlation coefficient was 0.409 (p = 0.05). In addition, based on 22 PET-CT scans, a strong and statistically significant positive correlation between testicular volume and age was documented (r = 0.67, p < 0.001). CONCLUSION: Whereas it was previously shown that in adult men there was a weak but statistically significant negative correlation between F-18 FDG uptake in the normal testis and age, we found a strong and statistically significant positive correlation in children and teenage boys.