Evaluating programs to prevent unintentional trauma in Canada: challenges and directions.

BACKGROUND: Trauma remains the number one cause of death for people under the age of 44 years and consumes a disproportionate amount of resources. This review describes the spectrum of prevention strategies in Canada, current behavior-oriented trauma prevention initiatives, and evaluations of their effectiveness. METHODS: A literature search of English language citations in MEDLINE was carried out by using the word "prevention" in conjunction with any of the words "injury," "accident," "trauma," "fall," "collision," and "traffic." Relevant material from bibliographies was also obtained. A comprehensive compilation of local and national prevention programs in Canada was reviewed. Only programs with reported evaluation data were included. CONCLUSION: Enforcing trauma prevention measures through legislation seems to be the most effective strategy. Educational models have not been adequately evaluated because of methodologic and economic constraints. New prevention initiatives must be supported with more resources and evaluation strategies. Involvement of health care professionals in prevention is encouraged.

Diagnosis of disseminated intravascular coagulation in dogs admitted to an intensive care unit.

OBJECTIVE: To describe and evaluate hemostatic function in critically ill dogs with clinical signs of diseases that predispose to disseminated intravascular coagulation (DIC). DESIGN: Prospective case series. ANIMALS: 59 critically ill dogs (affected dogs) with clinical signs of diseases known to predispose to DIC and 52 clinically normal dogs (control dogs). PROCEDURE: Activated partial thromboplastin time (aPTT), prothrombin time (PT), thrombin clotting time (TCT), plasma fibrinogen concentration, serum concentration of fibrin and fibrinogen-related antigens (FRA), and plasma antithrombin III (AT III) activity were determined for all dogs. Results from affected dogs were compared with those of control dogs. In some affected dogs, postmortem tissue specimens were examined for evidence of microvascular thrombosis. A diagnosis of DIC was made by fulfilling at least 3 of the following criteria: 1) abnormal aPTT, PT, or TCT value, 2) low plasma fibrinogen concentration, 3) low plasma AT III activity, 4) high serum FRA concentration, or 5) low platelet count. To evaluate the severity of hemostatic dysfunction, 3 arbitrary categories (mild, moderate, and severe) were proposed. RESULTS: A diagnostic strategy based on moderate hemostatic dysfunction identified DIC in 16 of 59 (27.1%) affected dogs. The AT III activity was < 70% in 15 of 16 dogs with DIC. Microvascular thrombosis was observed in tissue specimens from 7 of 8 affected dogs. Serum FRA and plasma fibrinogen concentrations did not contribute in establishing a diagnosis of DIC. CONCLUSIONS AND CLINICAL RELEVANCE: A diagnosis of DIC can be made when hemostatic dysfunction is moderate in dogs with clinical signs of diseases associated with DIC.

Evaluation of point-of-care tests for diagnosis of disseminated intravascular coagulation in dogs admitted to an intensive care unit.

OBJECTIVE: To evaluate the accuracy of point-of-care tests for the diagnosis of disseminated intravascular coagulation (DIC) in dogs and assess the correlation and agreement of results between point-of-care and laboratory tests in the evaluation of hemostatic function. DESIGN: Prospective case series. ANIMALS: 59 critically ill dogs (affected dogs) with clinical signs of diseases known to predispose to DIC and 52 clinically normal dogs. PROCEDURES: Accuracy of the point-of-care tests (activated clotting time [ACT], estimated platelet count and number of schizocytes from a blood smear, plasma total solids [TS] concentration, and the protamine sulfate test) was evaluated, using receiver operating characteristic curves and likelihood ratios. A strategy, using likelihood ratios to calculate a posttest probability of DIC, was tested with 65% used as a threshold for initiation of treatment. Results of laboratory tests (coagulogram and plasma antithrombin III activity) were used as the standard for comparison in each dog. RESULTS: ACT and estimated platelet count provided the best accuracy for detection of DIC. The plasma TS concentration, schizocyte number, and protamine sulfate test had poor accuracy. The strategy using post-test probability of DIC identified 12 of 16 affected dogs that had DIC. Estimated platelet count was correlated and had acceptable clinical agreement with automated platelet count (r = 0.70). The plasma TS (r = 0.28) concentration and serum albumin (r = 0.63) concentration were not accurate predictors of plasma antithrombin III activity. The ACT did not correlate with activated partial thromboplastin time (r = 0.28). CONCLUSIONS AND CLINICAL RELEVANCE: Strategic use of likelihood ratios from point-of-care tests can assist clinicians in making treatment decisions for dogs suspected to have DIC when immediate laboratory support is unavailable.

Transcranial Doppler penetrance of methyl methacrylate: technical note.

Methyl methacrylate is often used in cranioplasties and reconstructions of crainiectomies at sites through which transcranial Doppler (TCD) examinations are performed for assessment of cerebral hemodynamics. To assess the penetrance of methyl methacrylate by a transcranial Doppler ultrasound beam, methyl methacrylate discs of thickness from 4 to 10 mm were constructed and placed in the path of the ultrasound beam during routine-insonation of the middle cerebral artery and femoral artery in a healthy volunteer. The quality of ultrasound signals obtainable markedly deteriorated as thicker discs were used, and was almost completely absent at a thickness of 10 mm. The impairment of ultrasound transmission at frequencies used for transcranial Doppler ultrasound by methyl methacrylate is significant and represents a limitation in TCD studies that should be recognized by the clinician.

Quality of life after myocardial infarction.

The objective of this work was to develop and test a questionnaire to measure health-related quality of life for patients after myocardial infarction (MI). In a cross-sectional survey, 63 patients identified the most frequent and important problems following acute myocardial infarction. The Quality of Life after Myocardial Infarction (QLMI) instrument was developed on the basis of these most frequent and important problems. The QLMI was administered, along with instruments measuring health utilities, social function, and emotional function, in a randomized trial of rehabilitation versus conventional care. The most frequent and important problems fell into areas of symptoms, restriction, confidence, self-esteem, and emotions, each of which is represented in the 26-item QLMI. Effect sizes of the overall QLMI in differentiating between rehabilitation and control groups (0.35), and in detecting improvement over 12 months (1.22) were comparable or larger than any other instrument. The Pearson's correlation coefficient between QLMI administered at 8 and 12 months following AMI varied between 0.75 and 0.87 for the five domains and the overall score. We found substantial correlations of the QLMI with other measures with moderate concordance with predictions about how the instrument should behave if it is a valid measure of health-related quality of life. The QLMI demonstrates a high degree of reliability, and is more responsive than other questionnaires. Relations between the QLMI and other measures provide moderate to strong evidence of its validity in discriminating between patients following AMI according to their health-related quality of life, and in measuring changes in health-related quality of life over time.

Analysis of published studies on the detection of extrathoracic metastases in patients presumed to have operable non-small cell lung cancer.

BACKGROUND: A study was undertaken to determine the proportion of patients with potentially operable non-small cell lung cancer that could be spared thoracotomy by a systematic search for extrathoracic metastases. METHODS: An English language literature search was carried out using MEDLINE (1966-91) and bibliographic reviews of textbooks, review articles, and key articles. Studies were included in which at least 90% of the patients had histologically proven non-small cell cancer of the lung, were presumed otherwise operable, and for which the results of computed tomography of the head or abdomen, ultrasonography of the abdomen, or radionuclide imaging (scan) of bone or liver were available. Study quality and specific descriptive information concerning population, intervention, and outcome measurements were assessed. RESULTS: Of approximately 1500 citations which were screened, 100 were reviewed in detail and data abstracted from 16. The number of patients (total number, followed in square brackets by number of asymptomatic patients) shown to be inoperable directly as a result of the investigation and thus spared unnecessary thoracotomy was: computed tomography of the head: 26/785 (3.3%), 95% confidence interval (CI) 2.1% to 4.4% [14/353 (4.0%), 95% CI 2% to 6%], computed tomography of the adrenal glands: 30/632 (4.7%), 95% CI 3.0% to 6.4% [number asymptomatic indeterminate], bone scan: 45/480 (9.3%), 95% CI 6.7% to 12% [9/301 (3.0%), 95% CI 1.1% to 4.9%], liver imaging: 12/529 (2.3%), 95% CI 0.9% to 3.3% [4/268 (1.5%), 95% CI 0.1% to 3%]. CONCLUSIONS: A study with a large sample size and preferably incorporating thoracic computed tomography is required to narrow the confidence intervals around each test. All tests may play an important part in the preoperative evaluation of patients with non-small cell carcinoma of the lung who are presumed to be operable, including asymptomatic patients. Limitations of present data preclude definitive recommendations for asymptomatic patients.