Acute tracheoesophageal burst injury after blunt chest trauma: case report and review of the literature.
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Adolescent↗
Biomedical subjects
David S Mulder
Publications and source records attributed to David S Mulder.
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↗
Delays to surgery in non-small-cell lung cancer.
BACKGROUND: In Canada, waiting times for referral and surgery exist for both benign and malignant disease. We attempted to evaluate the length of various waiting times for surgery as well as their association with surgical stage in patients with non-small-cell lung cancer (NSCLC). METHODS: This observational study consisted of a retrospective review of data for all patients who underwent an operation with the intent to cure NSCLC between Jan. 1, 1993, and Dec. 31, 2002, at the Montreal General Hospital, McGill University Health Centre, Montréal, Que. Time intervals between multiple preoperative points and surgery were calculated. The patients were then linked via universal health care insurance numbers with data from the centralized provincial inclusive health care database. This allowed the calculation of the precise interval between the patients' first contact with a physician for symptoms related to their malignancy and surgery. Mean time intervals were then compared with surgical stage. RESULTS: We found adequate data for time interval analysis over 10 years for 256 patients who had undergone surgery with intent to cure. The distribution of patients by TNM stage was as follows: stage I, 144 patients (56.3%); stage II, 47 patients (18.4%); stage III, 41 patients (16.0%); and stage IV, 24 patients (9.4%). Mean and median time intervals between initial contact with physician or first onset of symptoms relating to lung cancer and surgery were 208 (standard deviation [SD] 313) days and 109 days, respectively. Mean and median time intervals between initial contact with the thoracic surgeon and surgery were 104 (SD 99) days and 82 days, respectively. No detrimental effect was observed between time to surgery and surgical stage in patients with NSCLC. CONCLUSIONS: Excessive preoperative waiting times before attempts at curative surgical resection for NSCLC exist in our centre. These intervals are exceptionally long, multifactorial and cause for concern.
Aged↗
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↗
Ten-year surgical experience with nontraumatic pericardial effusions: a comparison between the subxyphoid and transthoracic approaches to pericardial window.
HYPOTHESIS: The approach to pericardial window in patients with nontraumatic pericardial effusion impacts outcome. DESIGN: Retrospective review and comparison of all cases of pericardial window performed over 10 years. Follow-up was to patient death. SETTING: Three hospitals performing cardiothoracic surgery at a single university. PATIENTS: All patients in whom pericardial window was performed for nontraumatic pericardial effusion. MAIN OUTCOME MEASURES: Outcomes associated with the subxyphoid approach to pericardial window were compared with those associated with the transthoracic approach. The primary outcome was postsurgical recurrence of pericardial effusion. Secondary outcomes included operative time, intraoperative and postoperative complications, in-hospital mortality, hospital and intensive care unit lengths of stay, and days between surgery and death. RESULTS: Over 10 years, there were 342 patients with procedural codes for pericardial window in the medical record databases of 3 hospitals performing cardiothoracic surgery at 1 university center. One hundred fifty-one patients were excluded because the operation was performed for trauma, postoperative tamponade, or pericardial biopsy without effusion. The results are, therefore, based on the remaining 191 procedures. The subxyphoid approach was used in 78 patients, and the transthoracic approach in 113 patients. Patients were well matched for age (P = .31), sex (P = .05), preoperative tamponade (P = .08), and comorbidities (P > .05). No differences were observed between the 2 approaches in terms of recurrence of effusion, operative time, overall intraoperative or postoperative complications, and hospital or intensive care unit lengths of stay. In-hospital mortality was significantly greater in the subxyphoid group (27 of 78 vs 18 of 113 patients; P = .003). CONCLUSIONS: Over 10 years, there were 191 pericardial windows performed for nontraumatic pericardial effusions. The subxyphoid and transthoracic approaches were well tolerated by patients, required short operative times, and resulted in similar rates of overall postoperative complications and intensive care unit and hospital lengths of stay. Recurrence rates were low with both procedures.
Aged↗
The association between trauma system and trauma center components and outcome in a mature regionalized trauma system.
BACKGROUND: Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome. METHODS: Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity. RESULTS: Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99). CONCLUSIONS: Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.
Emergency Medical Service Communication Systems↗
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↗
The Montreal General Hospital, 1821-2002.
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History, 19th Century↗
Breast cancer diagnosis by scintimammography: a meta-analysis and review of the literature.
Scintimammography is a relatively new, non-invasive diagnostic modality in the evaluation of breast cancer. The purpose of the current study was to review the existing literature on the accuracy of scintimammography in the diagnosis of breast cancer. A search of all articles published between 1st January 1967 and 31st December 1999 was conducted. A total of 64 unique studies were selected. Each scientific paper was reviewed for scientific merit by an epidemiologist, a surgeon and a surgical resident. Assessment of scientific merit was based on a scoring scheme developed for the study. The articles included in this review reported data on a total of 5340 patients assessed for breast cancer with scintimammography. The aggregated summary estimates on these patients were sensitivity: 85.2% and specificity: 86.6%. For patients with a palpable mass the sensitivity and specificity were 87.8 and 87.5%, respectively. For patients without a palpable mass the sensitivity was 66.8% and that for specificity was 86.9%. The results of this review have shown that scintimammography may be used effectively as an adjunct to mammography and physical examination in the diagnosis of breast cancer.
Breast Neoplasms↗
Increasing volume of patients at level I trauma centres: is there a need for triage modification in elderly patients with injuries of low severity?
INTRODUCTION: Since the introduction of a regionalized trauma system in Quebec in 1993, patient loads at level I trauma centres have been increasing gradually. We aimed to investigate the type of patient presenting to 4 tertiary trauma centres in Quebec, the nature of their injuries and whether there was a need to modify triage protocols. METHODS: The study consisted of a review of major trauma patients entered into a regional trauma registry between Apr. 7, 1993, and Mar. 31, 2000. A total of 29 669 patients fulfilled the eligibility criteria. We compared patient demographics, injury type and severity and mechanism of injury. RESULTS: During the 7 years of the study, there was an increase in the volume and presentation of patients injured in falls (p < 0.01), patients with extremity injuries (p < 0.01), single injuries (p < 0.01) and injuries to single body regions (p < 0.01). Young patients were mostly injured in motor vehicle collisions and had multiple injuries of high severity whereas elderly patients were mostly injured in falls and experienced isolated extremity injuries of low severity. CONCLUSIONS: The proportion of elderly patients injured in falls, experiencing isolated extremity injuries of low severity and being treated at tertiary trauma centres in Quebec is overwhelmingly high. Revision of pre-hospital triage protocols should be considered and studied in order to transport trauma patients to appropriate facilities.
Accidental Falls↗
An expanding role for cardiopulmonary bypass in trauma.
OBJECTIVES: To analyze experience at the McGill University Health Centre with cardiopulmonary bypass (CPB) in trauma, complemented by a review of the literature to define its role globally and outline indications for its expanded use in trauma management. DATA SOURCES: All available published English-language articles from peer reviewed journals, located using the MEDLINE database. Chapters from relevant, current textbooks were also utilized. STUDY SELECTION: Nine relevant case reports, original articles or reviews pertaining to the use of CPB in trauma. DATA EXTRACTION: Original data as well as authors' opinions pertinent to the application of CPB to trauma were extracted, incorporated and appropriately referenced in our review. DATA SYNTHESIS: Overall mortality in the selected series of CPB used in the trauma setting was 44.4%. Four of 5 survivors had CPB instituted early (first procedure in operative management) whereas 3 of 4 deaths involved late institution of CPB. CONCLUSIONS: Although CPB has traditionally been used in the setting of cardiac trauma alone, a better understanding of its potential benefit in noncardiac injuries will likely make for improved outcomes in the increasingly diverse number of severely injured patients seen in trauma centres today. Further studies by other trauma centres will allow for standardized indications for the use of CPB in trauma.
Adolescent↗
Pain on a surgical ward: a survey of the duration and intensity of pain and the effectiveness of medication.
The effectiveness of analgesic medication for post-surgical pain was surveyed in a surgical ward of a large general hospital. Since earlier studies have shown that pain generally decreases rapidly and is negligible by the fourth day after surgery, the patients in the survey were assigned to 2 groups: those given analgesics during the first 4 days after surgery, and those given analgesics for pain after the fourth day. The results show that the patients with pain that persists beyond day 4 comprise a substantial proportion of the patients in a surgery ward (31%), are older, tend to use more words to describe their pain, and are helped less by their prescribed analgesic medications. This group is prescribed lower doses of analgesics and receives them more frequently; however, this prescription strategy appears to be ineffective since 26% of these patients report increased pain after medication compared to only 2% in the group that received analgesics during the first 4 days.
Analgesics↗