Biomedical subjects

Andre Lavoie

Publications and source records attributed to Andre Lavoie.

10 recordsLinked to original sources

PubMed2006

Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems?

BACKGROUND: Adverse outcomes for patients with isolated hip fracture have been documented when preoperative delay is longer than 48 hours. An efficient system will have the capacity to repair all hip fractures within 48 hours. We hypothesized that in an efficient system, there would be a medical justification for a delay greater than 48 hours. The purpose of this study was to identify the causes and outcome of delay for hip surgery in an efficient system. METHODS: All patients with isolated hip fracture admitted to a regional trauma center from April 1993 to March 2003 were reviewed. Demographics, presence of comorbidity, preoperative delay, complications, and mortality were collected. Univariate and multivariate analysis were carried out. RESULTS: The cohort included 977 patients. Overall mortality was 12.2%. Surgery was performed within 24 hours in 53% of cases and within 48 hours in 87% of cases. The presence of comorbidity partly explained longer (>48 hours) surgical delays. Multivariate analysis revealed that age greater than 65, male sex, and the presence of pulmonary and cardiac comorbid conditions or an active cancer but not surgical delay were associated with mortality and complications. However, surgical delay was associated with longer postsurgical hospital stay, independently of the presence of comorbidity or increasing age. CONCLUSIONS: Preoperative delay does not entail adverse outcomes when the surgery is delayed to allow for treatment of comorbid medical conditions. Preoperative delay is associated with a longer hospital stay. The presence of comorbidity only partly explains preoperative delay and adverse outcomes. A prospective study coding for the severity of comorbid conditions and the justification of the preoperative delay will be required to fully elucidate the link between delay and outcome.

Adult↗

PubMed2006

Functional status and quality of life in survivors of injury treated at tertiary trauma centers: what are we neglecting?

BACKGROUND: The purpose of this study was to describe the functional status and quality of life (QOL) of patients at 12 months after injury. METHODS: Retrospective study consisting of patients treated at three tertiary trauma centers for injuries. Functional capacity (FC) was measured using the Sickness Impact Profile and QOL was measured using the Medical Outcomes Study Short Form (MOS SF-36) at approximately 12 months after the date of injury. RESULTS: There were 144 patients that fulfilled the study inclusion and exclusion criteria. The mean duration of follow-up was 1.3 years, with a range of 0.8 to 1.5 years. Age and gender were not associated with the FC or QOL. The mean(standard deviation) Injury Severity Score (ISS) was 18.9(9.4), whereas ISS category distribution was 1 to 11 (22.9%), 12 to 24 (50.0%), and 25 to 49 (27.1%). Patients with an ISS of 25 to 49 had significantly worse physical (p = 0.008) and total (p = 0.023) Sickness Impact Profile scores and had more physical functioning (p = 0.096), emotional role functioning (p = 0.080), and energy (p = 0.017) impairments when compared with those with an ISS less than 24. Patients injured in motor vehicle collisions had significantly impaired psychosocial function (p = 0.031), whereas those injured in falls had reduced quality of life scores for physical function (p = 0.089), physical role (p = 0.066), and mental health (p = 0.081). CONCLUSION: Patients who survive injuries experience residual impairments in FC and QOL for as long as 1 year after injury. Changes to the long-term management of these patients should be considered.

Activities of Daily Living↗

PubMed2005

Clinical evaluation of the spine in the intoxicated blunt trauma patient.

The objective of the current study was to evaluate the accuracy of the clinical examination of the spine following blunt trauma in intoxicated patients. Methods included a retrospective review of all cases of blunt trauma presenting to an urban level I trauma centre over 1 year. Data was analysed separately for the clinical examination of the cervical spine (CS) and for the thoracic and lumbar spine (T + LS). Two hundred and sixteen cases of blunt trauma secondary to MVC (n = 143) or falls (n = 73) were retained for analysis. In intoxicated patients, sensitivities and specificities for CS tenderness were 60.0 and 64.3% (radiological abnormality) and 100 and 68.6% (operative stabilization), respectively. With respect to the T + LS in intoxicated patients; sensitivities and specificities for T + LS tenderness and radiological abnormality were 80.0 and 71.4% and for the ability of the clinical examination to pick up unstable T + LS fractures requiring operative stabilization 100 and 72.0%, respectively. Intoxicated blunt trauma patients may be able to have spine fractures requiring operative stabilization excluded using physical examination of the spine at presentation to the trauma center.

Alcoholic Intoxication↗

PubMed2005

Should patients with isolated hip fractures be included in trauma registries?

BACKGROUND: Patients with isolated hip fractures are frequently excluded from trauma registries. The goal of this study was to show that patients with these injuries have higher resource use and poorer outcomes than the rest of the trauma population. METHODS: The Quebec Trauma Registry was used to identify all trauma patients from April 1, 1998, to March 31, 2003. Patients who were dead on arrival at the emergency room were excluded. Isolated hip fracture (HIP) was defined as a diagnosis of a single fracture to the neck of the femur (Abbreviated Injury Scale 1990 codes 851808.3, 851810.3, 851812.3, and 851818.3) secondary to a fall and for which the Injury Severity Score was 9 or 10 (no other Abbreviated Injury Scale code higher than 1). Patients with all other trauma diagnosis (OT) were used for comparison. Outcome variables were length of hospital stay, length of intensive care unit (ICU) stay, in-hospital complications, and status and orientation at discharge. Chi-square and Wilcoxon rank-sum tests were used. RESULTS: There were 68,422 patients: 14,426 (21.1%) HIP patients and 53,996 (78.9%) OT patients. The median Injury Severity Score was 9 for HIP (range, 9-10) and 9 for OT (range, 1-75). Mean length of hospital stay was 18.4 days for HIP compared with 11.7 days for OT (p < 0.0001). HIP patients represented 29.5% of the total hospital stay. ICU stay was required for 1,353 HIP patients (9.4%) and for 12,395 (23.0%) OT patients (p < 0.0001). Mean ICU stay was 3.9 days for HIP compared with 5.5 days for OT (p = 0.0006). In-hospital mortality was 8.5% in HIP compared with 3.7% in OT (p < 0.0001). HIP represented 62.7% of patients referred for long-term care and 39.3% of patients referred to a rehabilitation center. CONCLUSION: Patients with HIP represented 21.1% of admissions while accounting for 42% of total days of hospitalization and 38% of deaths. Patients with hip fractures have a significantly higher risk of death, prolonged hospital stay, and complication rate, and are more often transferred to a rehabilitation center or to a long-term nursing home than the rest of the trauma population despite lower severity. They require multidisciplinary care typical of the rest of the trauma population and should be included in the trauma registry if the registry is to document the full outcome and resource use of the trauma population.

Adult↗

PubMed2005

Penetrating thoracoabdominal injuries in Quebec: implications for surgical training and maintenance of competence.

BACKGROUND: The frequency of penetrating trauma is low in Canada. Current recommendations for the care of patients with penetrating injuries originate from inner city trauma centres with a high volume of such injuries and may not apply to Canada. The purpose of this study was to review the incidence and treatment of penetrating thoracoabdominal injuries in the 4 tertiary trauma centres in Quebec. METHODS: We identified all patients with penetrating thoracic or abdominal injuries who were taken to any of the 4 tertiary trauma centres in the province of Quebec between Apr. 1, 1998, and Mar. 31, 2001. Patients who were dead on arrival were excluded. Only patients with an Abbreviated Injury Scale of 2 or greater for the thoracic or abdominal regions were included. RESULTS: In total, 245 patients meeting our inclusion criteria were identified. Of these 223 (91%) were male. The mean (and standard deviation) age was 33.8 (13.2) years; range 15-90 years. The median Injury Severity Score was 10 (range 4-75). Overall in-hospital mortality was 6.9%. There were 203 patients (82.8%) with thoracic injuries and 192 patients (78.4%) with abdominal injuries. Fifty (20.4%) of these patients had injuries to both regions. A thoracotomy was carried out in 48 (31.4%) of 153 patients who had injuries to the thorax, and the abdomen was explored in 133 (93.7%) of the 142 patients with abdominal injuries. The incidence of these injuries in the study period varied from 3 to 49 cases per centre. CONCLUSIONS: The annual incidence of penetrating thoracoabdominal injuries is extremely low in all 4 of Quebec's tertiary trauma centres, and the number of thoracoabdominal procedures is even lower. Such a low exposure may jeopardize education and clinical competence. We need to rethink our educational strategies both for residents and for continuing medical education. New approaches to training and maintenance of competence must be developed.

Abdominal Injuries↗

PubMed2004

Preinjury warfarin use among elderly patients with closed head injuries in a trauma center.

BACKGROUND: This study aimed to determine the impact of warfarin use on the severity of injury among elderly patients presenting with closed head injuries. METHODS: A cohort of patients 55 years of age or older with closed head injuries taken to a tertiary trauma center between April 1993 and March 2001 was retrospectively identified. Patient characteristics, mechanism of injury, type and severity of injury, and hospital survival data were obtained from the trauma registry. Each case then was reviewed for completeness of information, assessment of preinjury warfarin use, and comorbidity. RESULTS: Among the 384 patients presenting with closed head injuries, 35 (9%) were receiving warfarin before their trauma. As compared with nonusers, anticoagulated patients had a higher frequency of isolated head trauma (54% vs. 32%; p = 0.008), more severe head injuries (65.7% vs. 44.1%; p = 0.02), and a higher rate of mortality (40% vs. 21%, p = 0.01). These associations remained evident even after population differences in age, gender, comorbidities, and mechanism of injury were taken into account. Indeed, according to multivariate logistic regression models, warfarin use was associated with a statistically significant risk of death (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.22-6.12), statistically significant odds for more severe head injury (OR, 2.39; 95% CI, 1.10-5.17), and odds for isolated head injury that almost reached statistical significance (OR, 1.79; 95% CI, 0.82-3.90). CONCLUSIONS: Among patients 55 years of age or older who present with closed head injury, the use of warfarin before trauma appears to be associated with a higher frequency of isolated head trauma, more severe head trauma, and a higher likelihood of death. The findings of this retrospective study support the concern about the adverse effects of anticoagulants in cases of head trauma.

Aged↗

PubMed2004

Implementation of a trauma care system: evolution through evaluation.

BACKGROUND: The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present. METHODS: A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes. RESULTS: Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002. CONCLUSION: A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.

Emergency Medical Services↗

PubMed2004

Improving the TRISS methodology by restructuring age categories and adding comorbidities.

BACKGROUND: The Trauma and Injury Severity Score (TRISS) methodology was developed to predict the probability of survival after trauma. Despite many criticisms, this methodology remains in common use. The purpose of this study was to show that improving the stratification for age and adding an adjustment for comorbidity significantly increases the predictive accuracy of the TRISS model. METHODS: The trauma registry and the hospital administrative database of a regional trauma center were used to identify all blunt trauma patients older than 14 years of age admitted with International Classification of Diseases, Ninth Revision codes 800 to 959 from April 1993 to March 2001. Each individual medical record was then reviewed to ascertain the Revised Trauma Score, the Injury Severity Score, the age of the patients, and the presence of eight comorbidities. The outcome variable was the status at discharge: alive or dead. The study population was divided into two subsamples of equal size using a random sampling method. Logistic regression was used to develop models on the first subsample; a second subsample was used for cross-validation of the models. The original TRISS and three TRISS-derived models were created using different categorizations of Revised Trauma Score, Injury Severity Score, and age. A new model labeled TRISSCOM was created that included an additional term for the presence of comorbidity. RESULTS: There were 5,672 blunt trauma patients, 2,836 in each group. For original TRISS, the Hosmer-Lemeshow statistic (HL) was 179.1 and the area under the receiver operating characteristic (AUROC) curve was 0.873. Sensitivity and specificity were 99.0% and 27.8%, respectively. For the best modified TRISS model, the HL statistic was 20.35, the AUROC curve was 0.902, the sensitivity was 99.0%, and the specificity was 27.8%. For TRISSCOM, the HL statistic was 14.95 and the AUROC curve was 0.918. Sensitivity and specificity were 99.0% and 29.7%, respectively. The difference between the two models almost reached statistical significance (p = 0.086). When TRISSCOM was applied to the cross-validation group, the HL statistic was 10.48 and the AUROC curve was 0.914. The sensitivity was 98.6% and the specificity was 34.9%. CONCLUSION: TRISSCOM can predict survival more accurately than models that do not include comorbidity. A better categorization of age and the inclusion of comorbid conditions in the logistic model significantly improves the predictive performance of TRISS.

Adolescent↗

PubMed2003

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia.

BACKGROUND: The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS: Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION: Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.

Aged↗

PubMed2002

Field triage of trauma patients: improving on the Prehospital Index.

The purpose of the present study was to evaluate the predictive ability of the Prehospital Index (PHI) in identifying injury severity and to develop a trauma triage scale that incorporates, along with the PHI, a subset of time independent variables to improve the predictive ability of the PHI-based triage instrument. This study included 1,291 trauma patients treated in Montreal, Canada. The developed trauma triage protocol was based on logistic regression analysis, in which the model that predicts the data best was selected by using Bayesian information criterion. The selected regression model included the variables age, body region injured, mechanism of injury, comorbidity, and PHI. This algorithm was a substantial improvement in detecting major versus non-major injuries (major injury defined based on death, intensive care unit admission, and surgery intervention) over the PHI alone (area under the receiver operating characteristic curve: 0.76 v 0.66, P <.05). Considering time independent variables could lead to better injury triage decisions.

Adolescent↗