Quantitative longitudinal T2* mapping for assessing placental function and association with adverse pregnancy outcomes across gestation.

Existing methods for evaluating in vivo placental function fail to reliably detect pregnancies at-risk for adverse outcomes prior to maternal and/or fetal morbidity. Here we report the results of a prospective dual-site longitudinal clinical study of quantitative placental T2* as measured by blood oxygen-level dependent magnetic resonance imaging (BOLD-MRI). The objectives of this study were: 1) to quantify placental T2* at multiple time points across gestation, and its consistency across sites, and 2) to investigate the association between placental T2* and adverse outcomes. 797 successful imaging studies, at up to three time points between 11 and 38 weeks of gestation, were completed in 316 pregnancies. Outcomes were stratified into three groups: (UN) uncomplicated/normal pregnancy, (PA) primary adverse pregnancy, which included hypertensive disorders of pregnancy, birthweight <5th percentile, and/or stillbirth or fetal death, and (SA) secondary abnormal pregnancy, which included abnormal prenatal conditions not included in the PA group such as spontaneous preterm birth or fetal anomalies. Of the 316 pregnancies, 198 (62.6%) were UN, 70 (22.2%) PA, and 48 (15.2%) SA outcomes. We found that the evolution of placental T2* across gestation was well described by a sigmoid model, with T2* decreasing continuously from a high plateau level early in gestation, through an inflection point around 30 weeks, and finally approaching a second, lower plateau in late gestation. Model regression revealed significantly lower T2* in the PA group than in UN pregnancies starting at 15 weeks and continuing through 33 weeks. T2* percentiles were computed for individual scans relative to UN group regression, and z-scores and receiver operating characteristic (ROC) curves calculated for association of T2* with pregnancy outcome. Overall, differences between UN and PA groups were statistically significant across gestation, with large effect sizes in mid- and late- pregnancy. The area under the curve (AUC) for placental T2* percentile and PA pregnancy outcome was 0.71, with the strongest predictive power (AUC of 0.76) at the mid-gestation time period (20-30 weeks). Our data demonstrate that placental T2* measurements are strongly associated with pregnancy outcomes often attributed to placental insufficiency. Trial registration: ClinicalTrials.gov: NCT02749851.

Methods for determining healthy body weight in end stage renal disease.

Several formulas for calculating desirable body weight are used in chronic kidney failure patients. Ideal body weight (IBW) derived from Metropolitan Life Insurance tables has been available since the 1950s. The Hamwi formula was proposed in the 1960s as a simple tool for quickly estimating desirable body weight, especially in people with diabetes. Since the 1970s, National Health and Nutrition Evaluation Surveys I, II, and III have provided an in-depth evaluation of the average body weights of Americans. These standard body weights (SBW) are often interpreted to be normal and healthy weight goals. Body mass index (BMI) has also been studied for decades and is used internationally as the standard for determining healthy weight, especially in relationship to obesity. These 4 methods are discussed and compared along with a brief review of the history of using the adjusted body weight (ABW) formulas, followed by recommendations for clinical practice.

Inclusion of 'minor' trauma cases provides a better estimate of the total burden of injury: Queensland Trauma Registry provides a unique perspective.

INTRODUCTION: Injury is recognised as a frequent cause of preventable mortality and morbidity; however, incidence estimates focusing only on the extent of mortality and major trauma may seriously underestimate the magnitude of the total injury burden. There currently exists a paucity of information regarding minor trauma, and the aim of this study was to increase awareness of the contribution of minor trauma cases to the total burden of injury. METHODS: The demographics, injury details, acute care factors and outcomes of both minor trauma cases and major trauma cases were evaluated using data from the state-wide trauma registry in Queensland, Australia, from 2005 to 2010. The impact of changes in Abbreviated Injury Scale (AIS) versions on the classification of minor and major injury cases was also assessed. RESULTS: Over the 6-year period, minor cases [Injury Severity Score (ISS) ≤ 12] accounted for almost 90% of all trauma included on the Queensland Trauma Registry (QTR). These cases utilised more than half a million acute care bed days, underwent more than 66,500 operations, and accounted for more than 48,000 patient transport episodes via road ambulance, fixed wing aircraft, or helicopter. Furthermore, more than 5800 minor trauma cases utilised in-hospital rehabilitation services; almost 3000 were admitted to an ICU; and more than 20,000 were admitted to hospital for greater than one week. When using the contemporary criteria for classifying trauma (AIS 08), the proportion of cases classified as minor trauma (87.7%) and major trauma (12.3%) were similar to the proportion using the traditional criteria for AIS90 (87.9% and 12.1%, respectively). CONCLUSIONS: This evaluation of minor trauma cases admitted to public hospitals in Queensland detected high levels of demand placed on trauma system resources in terms of acute care bed days, operations, ICU admissions, in-hospital rehabilitation services and patient transportation, and which are all associated with high cost. These data convincingly demonstrate the significant burden of injury imposed by minor trauma cases serious enough to be admitted to hospital.

The epidemiology of horse-related injuries for different horse exposures, activities, and age groups in Queensland, Australia.

BACKGROUND: The dangers associated with horse riding, a popular activity throughout Australia, are well documented; yet, few studies have comprehensively described injuries caused by horses to nonriders. This study aimed to facilitate targeted injury prevention strategies and appropriate trauma management by describing all horse-related injuries, for both riders and nonriders, in Queensland, and identifying those at greatest risk. METHODS: Horse-related injury data from 2005 to 2009 were extracted from the Queensland Trauma Registry. Descriptive comparisons were undertaken for demographic, injury, and acute care characteristics between riders and nonriders, between pediatric and adult cases, and between sports/leisure and work injuries. The relative risk of surgery by sex and between riders and nonriders was assessed. RESULTS: More than 25% of injuries occurred in people not riding a horse. Nonriders sustained a significantly higher proportion of internal organ injuries, open wounds, as well as facial and pelvic/abdominal injuries. Females accounted for more than 80% of children who were injured while riding a horse. For adults, 25% were injured while working, and more than 66% of injured workers were male. Injuries most commonly occurred in regional areas. Surgery was most common among children, nonriders, and those with Injury Severity Score (ISS) of 1 to 8. The likelihood of surgery was 25% higher for nonriders (95% confidence interval, 1.14-1.38%). CONCLUSION: Horse-related injuries are most prevalent in identifiable populations, particularly young female riders and adult males injured while working. Injuries inflicted by horses to nonriders contribute more than 27% of all horse-related injuries; however, most previous research has been limited to injured riders. Compared with riders, nonriders more frequently sustain internal, facial, and pelvic injuries; are male; and undergo surgery. The results of this study may be used to tailor prevention strategies and inform trauma management specific to the type of horse exposure, patient age, and activity engaged in when injured. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Mapping Abbreviated Injury Scale data from 1990 to 1998 versions: a stepping-stone in the contemporary evaluation of trauma.

INTRODUCTION: Many trauma registries have used the 1990 revision of the Abbreviated Injury Scale (AIS; AIS90) to code injuries sustained by trauma patients. Due to changes made to the AIS codeset since its release, AIS90-coded data lacks currency in the assessment of injury severity. The ability to map between the 1998 revision of AIS (AIS98) and the current (2008) AIS version (AIS08) already exists. The development of a map for transforming AIS90-coded data into AIS98 would therefore enable contemporary injury severity estimates to be derived from AIS90-coded data. METHODS: Differences between the AIS90 and AIS98 codesets were identified, and AIS98 maps were generated for AIS90 codes which changed or were not present in AIS98. The effectiveness of this map in describing the severity of trauma using AIS90 and AIS98 was evaluated using a large state registry dataset, which coded injury data using AIS90 over several years. Changes in Injury Severity Scores (ISS) calculated using AIS90 and mapped AIS98 codesets were assessed using three distinct methods. RESULTS: Forty-nine codes (out of 1312) from the AIS90 codeset changed or were not present in AIS98. Twenty-four codes required the assignment of maps to AIS98 equivalents. AIS90-coded data from 78,075 trauma cases were used to evaluate the map. Agreement in calculated ISS between coded AIS90 data and mapped AIS98 data was very high (kappa=0.971). The ISS changed in 1902 cases (2.4%), and the mean difference in ISS across all cases was 0.006 points. The number of cases classified as major trauma using AIS98 decreased by 0.8% compared with AIS90. A total of 3102 cases (4.0%) sustained at least one AIS90 injury which required mapping to AIS98. CONCLUSIONS: This study identified the differences between the AIS90 and AIS98 codesets, and generated maps for the conversion process. In practice, the differences between AIS90- and AIS98-coded data were very small. As a result, AIS90-coded data can be mapped to the current AIS version (AIS08) via AIS98, with little apparent impact on the functional accuracy of the mapped dataset produced.

A comparison of injuries to moped/scooter and motorcycle riders in Queensland, Australia.

BACKGROUND: The popularity of moped and motor scooter riding in Australia is increasing. However, there is a paucity of information about their safety, especially in comparison to motorcycle riding where riders require specific licensing, education and training. Given it is widely established that motorcycle riders are overrepresented in road injury statistics, consideration of moped and scooter riders as a sub-group of all motorcyclists is required for accurate understanding of injury patterns and the acute care needs of this group. METHOD: A comparison of demographic, injury and acute care characteristics between seriously injured moped/scooter riders and motorcycle riders was undertaken using data from the state-wide trauma registry in Queensland, Australia, from 2006 to 2010. RESULTS: A total of 206 moped/scooter riders and 2667 motorcycle riders were identified. Motorcycle rider injury admissions significantly decreased over time (p<0.01), whereas no change was observed for injured moped/scooter riders. Moped/scooter riders sustained a greater percentage of head/neck (+8.6%), facial (+3.0%) and abdominal injuries (+2.3%), whereas motorcycle riders sustained a greater percentage of upper extremity (+4.0%), thoracic (+3.9%), spinal (+3.6%) and lower extremity injuries (+2.6%). There was no statistically significant difference in injury severity, length of acute hospital stay, admission to ICU or survival to discharge from acute care between injured moped/scooter riders and motorcycle riders. CONCLUSION: The results of this study suggest that riders of mopeds/scooters and motorcycles may have different injury patterns, but sustain similar overall injury severity. This analysis fills a gap in transport crash data, where there is limited information on the nature of injuries sustained. While moped-related injuries cannot be isolated in ICD-10 health coding, it is anticipated that ICD-11, due for release in 2015, may provide a moped-specific code; however, this will not address the issue of the apparent interchangeable use of the terms 'moped' and 'scooter' when reporting or documenting such injuries in health data systems including the medical record. Improved identification of moped-related cases in health data is required to increase potential for linkage across health and transport crash data, which may be used for further evaluation of injuries sustained by moped and scooter riders.

Variations in indicated care of patients with acute coronary syndromes in Queensland hospitals.

OBJECTIVE: To identify variation in the rates of use of key evidence-based therapies and in clinical outcomes among patients hospitalised with acute coronary syndromes (ACS). DESIGN: Retrospective analysis of data on care processes and clinical outcomes of representative patient samples recorded by the Queensland Health Cardiac Collaborative registry. SETTING: 18 public hospitals (3 tertiary, 15 non-tertiary) in Queensland, August 2001 to December 2003. STUDY POPULATION: 2156 patients who died or were discharged after troponin-positive ACS. MAIN OUTCOME MEASURES: Comparison of proportions of highly eligible patients receiving indicated care and in-hospital mortality between subgroups categorised by age, sex, comorbidities (diabetes, renal failure, chronic obstructive pulmonary disease and mental disorder), type of admitting hospital (tertiary or non-tertiary), and cardiologist involvement (transfer or non-transfer to cardiology unit). RESULTS: Patients aged > or = 65 years were less likely than younger patients to receive heparin (79% v 87%), beta-blockers (79% v 87%), lipid-lowering agents (78% v 87%), coronary angiography (51% v 66%), and referral to cardiac rehabilitation (17% v 33%). Patients with diabetes were less likely than others to receive coronary angiography (50% v 63%), while those with moderate to severe renal failure were less likely to receive thrombolysis (52% v 84%), heparin (71% v 83%), beta-blockers (69% v 84%), lipid-lowering agents (61% v 84%), in-hospital cardiac counselling (46% v 64%) and referral to cardiac rehabilitation (9% v 25%). Patients admitted to tertiary hospitals were more likely than those admitted to non-tertiary hospitals to receive coronary angiography (85% v 55%) and referral to cardiac rehabilitation (36% v 21%). Risk-adjusted mortality was highest in patients with moderate to severe renal failure (15% v 3%) and older patients (6% v 2%). CONCLUSIONS: Variations exist in the provision of indicated care to patients with ACS according to age, diabetic status, renal function and type of admitting hospital. Excess mortality in elderly patients and in those with advanced renal disease may be partially attributable to failure to use key therapies.

A review of guidelines for nutrition care of renal patients.

The third edition of the Guidelines for Nutrition Care of Renal Patients has been developed to follow the American Dietetic Association's Medical Nutrition Therapy (MNT) Protocol format and to further assist dietitians in providing optimal and consistent care to renal patients. The guidelines define the level, content, and frequency of nutrition care that is appropriate based on the best available scientific information and expert opinion. Seven separate guidelines, primarily written for care provided in the outpatient setting, are defined in the publication. Each guideline focuses on a different patient population and/or treatment modality for renal disease: Pre-End-Stage Renal Disease, Hemodialysis and Peritoneal Dialysis, Hospitalized Dialysis, Transplantation, Acute Renal Failure, Enteral/Parenteral Nutrition Support, and Pregnancy in Renal Disease. The Guidelines for Nutrition Care of Renal Patients, Third Edition is meant to support and assist dietitians as providers of MNT in kidney disease, to provide uniform treatment care guidelines and nutritional status identification criteria for all aspects of kidney disease and its complications, and to help secure the dietitian as the provider of these services for optimum cost-effective care. The guidelines should help to increase effectiveness of care by promoting consistency among practitioners and should facilitate the measurement of the quality and effectiveness of care.

Multisite, quality-improvement collaboration to optimise cardiac care in Queensland public hospitals.

OBJECTIVE: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration. DESIGN: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003. SETTING: Nine public hospitals in Queensland. STUDY POPULATIONS: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF). INTERVENTION: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group. MAIN OUTCOME MEASURE: Changes in process-of-care indicators between baseline and post-intervention periods. RESULTS: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving beta-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF. CONCLUSION: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.