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Biomedical subjects

G A Wells

Publications and source records attributed to G A Wells.

At least 55 records · Page 3Linked to original sources
PubMed1999

Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ontario Prehospital Advanced Life Support.

STUDY OBJECTIVES: This study was conducted to identify modifiable factors associated with survival for prehospital cardiac arrest in a large, multicenter EMS system with basic life support/defibrillation (BLS-D) level of care. METHODS: This observational cohort study constitutes Phase I of the 3-phase Ontario Prehospital Advanced Life Support (OPALS) Study. Included were all adults who had cardiac arrest before EMS arrival in 21 urban/suburban communities that operate under the jurisdiction of 1 ambulance services branch, have 911 telephone service, and provide ambulance defibrillation but no prehospital advanced life support (ALS). Central dispatch and ambulance records were reviewed according to the Utstein guidelines. Associations between multiple patient and EMS factors and survival to discharge were assessed by univariate then stepwise logistic regression analyses. RESULTS: From January 1, 1991, to January 31, 1995, 5,335 eligible patients were treated. Of these, 46.8% of cardiac arrests were witnessed by citizens, 14.5% received bystander CPR, 25.6% received CPR by fire or police, and 38.2% had an initial rhythm of ventricular fibrillation/ventricular tachycardia (VF/VT). The mean interval from call received to vehicle stopped was 6.7 minutes. Survival was 3.5% overall and 8.8% for VF/VT. Multivariate analysis found the following factors to be independently associated with survival (odds ratio with 95% confidence intervals): age.81 (. 73,.89), bystander-witnessed arrest 4.05 (2.78, 5.90), bystander CPR 2.98 (2.07, 4.29), CPR by fire or police 2.20 (1.46, 3.31), and response interval call received to vehicle stopped.76 (.71,.82). CONCLUSION: This represents the largest multicenter BLS-D study of prehospital cardiac arrest yet conducted and clearly indicates that patient survival may be improved by optimization of EMS response intervals, bystander CPR, as well as first-responder CPR by fire or police.

Adolescent↗
PubMed1999

Assessing the quality of randomized trials: reliability of the Jadad scale.

An instrument was developed and validated by Jadad, et al. to assess the quality of clinical trials using studies from the pain literature. Our study determined the reliability of the Jadad scale and the effect of blinding on interrater agreement in another group of primary studies. Four raters independently assessed blinded and unblinded versions of 76 randomized trials. Interrater agreement was calculated among combinations of four raters for blinded and unblinded versions of the studies. A 4 x 2 x 2 repeated measures design was employed to evaluate the effect of blinding. The interrater agreement for the Jadad scale was poor (kappa 0.37 to 0.39), but agreement improved substantially (kappa 0.53 to 0.59) with removal of the third item (an explanation of withdrawals). Blinding did not significantly affect the Jadad scale scores. A more precise description of how to score the withdrawal item and careful conduct of a practice set of articles might improve interrater agreement. In contrast with the conclusions reached by Jadad, we were unable to demonstrate a significant effect of blinding on the quality scores.

Double-Blind Method↗
PubMed1999

Clusterin in bovine spongiform encephalopathy (BSE).

Clusterin mRNA, detected in increased quantities in the cervical spinal cord of cattle with bovine spongiform encephalopathy (BSE), was localized mainly in the neuroglia (including astrocytes) of the lateral and ventral areas of white matter. Axonal degeneration was also observed in these areas. The dorsal horns of the spinal cord in which BSE prion protein (PrP(BSE)) was deposited did not exhibit strong clusterin "up-regulation" but showed increased clusterin immunolabelling with a punctate distribution in the neuropil. Labelling of adjacent sections of the grey matter in BSE-affected spinal cord and thalamus demonstrated that the clusterin was deposited in association with extracellular PrP(BSE).

Animals↗
PubMed1999

Renal neoplasia in coypus (Myocastor coypus).

Renal neoplasia is described in coypus (Myocastor coypus) from a feral population of the species in East Anglia. A population control campaign was started in 1962, and in 1981 this became an eradication scheme. From 1976 onwards, a research programme included the postmortem examination of 9400 wild caught and captive coypus. During the period 1980-91, 15 cases (0.16%) of renal neoplasia were detected. The tumours were found in both sexes between estimated ages of 25 months and 13 years with no significant sex prevalence. There was no clear evidence that renal tumours were more common in older animals. Tumours were most common in captive coypus and were bilateral in approximately half of the animals. In all cases, the tumours were of epithelial type resembling adenomata and adenocarcinomata of other animals. Most were clearly benign, and, although some showed evidence of malignancy, no unequivocal evidence of metastasis was established. The prevalence of renal tumours in this series is greater than that recorded in previous published surveys of coypus and other rodents. This may relate to the origin of the coypus population, differences in age structure in animals examined, and the varied conditions under which the rodents lived. Aetiological factors remain undetermined.

Adenocarcinoma↗
PubMed1999

What is the quality of life for survivors of cardiac arrest? A prospective study.

OBJECTIVE: To evaluate the quality of life of survivors of in-hospital and out-of-hospital cardiac arrest, and to correlate quality of life with clinically important parameters. METHODS: Cohort followed at least six months after hospital discharge. Eligible patients had survived to hospital discharge after sudden cardiac arrest in 1) EDs, wards, and intensive care units of five university hospitals and 2) all locations outside hospitals in two midsized cities. Of 126 patients discharged alive, 30 died before they could be interviewed. Of the 96 patients remaining, 86 (90% of available patients, 68% of survivors to discharge) completed the interview. Quality of life was assessed with the Health Utilities Index Mark 3, which describes health as a utility score on a scale from perfect health (equal to 1.0) to death (equal to 0.) RESULTS: Mean age (+/- SD) of interviewed survivors was 65 +/- 14 years, and 47 (55%) were male; mean time between collapse and initiation of CPR was 2.2 +/- 2.6 minutes. Mean utility was 0.72 (+/- 0.22). Utilities were significantly higher among patients who had a shorter duration of resuscitation (mean = 0.81 for those who received less than 2 minutes of CPR, 0.76 for those who received 3 to 10 minutes, and 0.65 for others, p = 0.05, r2 = 0.07). Mean utilities of survivors were worse than those of the general population (mean = 0.85 +/- 0.16, p < 0.01) and those whose activities were not limited by chronic disease (mean = 0.91 +/- 0.08, p < 0.01). CONCLUSIONS: Although overall survival was poor, most survivors had acceptable health-related quality of life. Therefore, concerns about poor quality of life are not a valid reason to abandon efforts to improve the health care system's response to victims of sudden cardiac arrest. Further research is necessary to identify effective strategies for improving both survival and quality of life after cardiac arrest.

Aged↗
PubMed1999

Neuropsychological sequelae of haemolytic uraemic syndrome. Investigators of the HUS Cognitive Study.

BACKGROUND: Severe haemolytic uraemic syndrome (HUS) in childhood can cause stroke, hemiplegia, cortical blindness, and psychomotor retardation. These outcomes are evident at the time of discharge immediately after the acute illness. Less is known about the neuropsychological outcomes of less severely affected children who recover from acute HUS. AIMS: This multicentre case control study investigated the hypothesis that children who survive an acute episode of HUS without recognizable neurological injuries have greater impairment of cognitive, academic, and behavioural functions than controls. DESIGN: Children with HUS were eligible if they had no evidence of severe neurological dysfunction when discharged from one of six Canadian hospitals. Controls had been admitted to hospital for a non-HUS illness and were matched by age, sex, first language, and socioeconomic status. All subjects underwent evaluation of behaviour, academic achievement, cognitive function, and verbal abilities using standardised tests administered by a psychometrist blinded to the case or control status. RESULTS: Ninety-one case control pairs were enrolled. No important differences between patients with HUS and paired controls were evident on tests of IQ, behaviour, verbal abilities, or academic achievement. There was no increased risk of attention deficit disorder among patients with HUS. There was no correlation between the severity of acute renal failure and neuropsychological measures, although scores on some verbal ability tests were lower in those with the highest serum creatinine concentrations during illness. CONCLUSIONS: Children discharged from hospital without apparent neurological injury after an episode of acute HUS do not have an increased risk of subclinical problems with learning, behaviour, or attention.

Acute Disease↗
PubMed1999

An economic analysis of the Ottawa knee rule.

STUDY OBJECTIVE: To conduct an economic analysis of the implementation of the Ottawa Knee Rule. METHODS: The decision analysis compared usual practice based on physician judgment with practice based on a clinical decision rule, which allows more selective use of radiography. The study participants were all adults with blunt knee trauma. The likelihood and cost of radiography, missed fracture, lost productivity, and medicolegal actions were defined by published data and an expert panel. Separate analyses considered US Medicare and Canadian hospital costs. Sensitivity analyses considered a range of values for each variable in the model, including costs in a US fee-for-service setting. The study outcome was the mean cost per patient. RESULTS: The mean cost savings associated with practice based on the Ottawa Knee Rule was $31 (95% confidence interval 22 to 44) to $34 (95% confidence interval 24 to 47) per patient. These results were robust to reasonable changes in the values of variables in the model. CONCLUSION: Implementation of the Ottawa Knee Rule would be associated with meaningful reductions in societal health care costs both in the United States and Canada without a reduction in quality of care.

Adult↗
PubMed1999

A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest.

STUDY OBJECTIVE: More than 1,000 patients experience sudden cardiac arrest each day. Treatment for this includes cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) that provide CPR-basic life support (BLS), BLS with defibrillation (BLS-D), or advanced life support (ALS). Our previous systematic review of treatments for sudden cardiac arrest was limited by suboptimal data. Since then, debate has increased about whether bystander CPR is effective or whether attention should focus instead on rapid defibrillation. Therefore a cumulative meta-analysis was conducted to determine the relative effectiveness of differences in the defibrillation response time interval, proportion of bystander CPR, and type of EMS system on survival after out-of-hospital cardiac arrest. METHODS: A comprehensive literature search was performed by using a priori exclusion criteria. We considered EMS systems that provided BLS-D, ALS, BLS plus ALS, or BLS-D plus ALS care. A generalized linear model was used with dispersion estimation for random effects. RESULTS: Thirty-seven eligible articles described 39 EMS systems and included 33,124 patients. Median survival for all rhythm groups to hospital discharge was 6.4% (interquartile range, 3.7 to 10.3). Odds of survival were 1.06 (95% confidence interval [CI], 1.03 to 1.09; P <.01) per 5% increase in bystander CPR. Survival was constant if the defibrillation response time interval was less than 6 minutes, decreased as the interval increased from 6 to 11 minutes, and leveled off after 11 minutes (P <.01). Compared with BLS-D, odds of survival were as follows: ALS, 1. 71 (95% CI, 1.09 to 2.70; P =.01); BLS plus ALS, 1.47 (95% CI, 0.89 to 2.42; P =.07); and BLS with defibrillation plus ALS, 2.31 (95% CI, 1.47 to 3.62; P <.01.) CONCLUSION: We confirm that greater survival after sudden cardiac arrest is associated with provision of bystander CPR, early defibrillation, or ALS. More research is required to evaluate the relative benefit of early defibrillation versus early ALS.

Electric Countershock↗
PubMed1998

Potential cost-effectiveness of public access defibrillation in the United States.

BACKGROUND: Approximately 360,000 Americans experience sudden cardiac arrest each year; current treatments are expensive and not very effective. Public access defibrillation (PAD) is a novel treatment for out-of-hospital sudden cardiac arrest that refers to use of automated external defibrillators by the lay public or by nonmedical personnel such as police. A clinical trial has been proposed to evaluate the effectiveness of public access defibrillation, but it is unclear whether such early defibrillation will offer sufficient value for money. Our objective was to estimate the potential cost-effectiveness of public access defibrillation by use of decision analysis. METHODS AND RESULTS: A decision model compared the potential cost-effectiveness of standard emergency medical services (EMS) systems with that of EMS supplemented by PAD. We considered defibrillation by lay responders or police, using an analysis with a US health-care perspective. Input data were derived from published data or fiscal databases. Future costs and effects were discounted at 3%. Monte Carlo simulation was performed to estimate the variability in the costs and effects of each program. Sensitivity analyses assessed the robustness of the results to changes in input data. A standard EMS system had a median cost of $5900 per cardiac arrest patient (interquartile range, IQR, $3200 to $10,900) and yielded a median of 0.25 quality-adjusted life years (IQR, 0.20 to 0.30). PAD by lay responders had a median incremental cost of $44,000 per additional quality-adjusted life year (IQR, $29,000 to $68,900). PAD by police had a median incremental cost of $27,200 per additional quality-adjusted life year (IQR, $15,700 to $47,800). The results were sensitive to changes in the cost and relative survival benefit of PAD. CONCLUSIONS: Although more expensive than standard EMS for sudden cardiac arrest, PAD may be economically attractive. The effectiveness and cost-effectiveness of PAD should be assessed in a randomized, controlled trial.

Cost-Benefit Analysis↗
PubMed1998

Back pain in a large Canadian police force.

STUDY DESIGN: A survey of a random sample of 1002 members of the Royal Canadian Mounted Police to determine their experience with low back pain. OBJECTIVES: To determine the prevalence of low back pain among Royal Canadian Mounted Police members and to assess the validity of the perception that the patrol car seat and the duty belt are causing a higher rate of low back pain among members of the Royal Canadian Mounted Police than in the general population. SUMMARY OF BACKGROUND DATA: Low back pain is a common problem throughout the industrialized world, with reported 1-year prevalence rates between 25% and 62%. Prevalence of low back pain among people who drive motor vehicles for a significant part of the day appears higher than in the general population. Among police officers, 1-year prevalence rates of between 44% and 62% have been reported. METHODS: A computerized database of 14,897 serving regular members was used to identify a sample of officers on active duty. A low back pain questionnaire was mailed to each selected member, eliciting information regarding their experience with low back pain, their exposure to known and putative risk factors, and their opinions about the contribution of these potential risk factors. The respondents to the questionnaire remained anonymous. RESULTS: The response rate was 80%. The prevalence of "chronic or recurring low back pain since joining the force" was 54.9%, which is comparable with the lifetime prevalence reported for the general population. Of those who reported having back problems, only 8.5% had such problems before joining the force. Seventy-six percent who had low back pain reported having a problem within the last year, giving an overall 1-year prevalence of 41.8%, which is comparable with that for the general population. The a priori assumption that driving or wearing a duty belt contributed to the problem was shared by most police officers surveyed. However, only about half of the members who replied drove for more than half the working day or wore the duty belt. These members had the same prevalence of low back pain as those who did not drive or wear the duty belt. CONCLUSIONS: The prevalence of low back pain in this police force is comparable with that in the general population, and driving a patrol car or wearing the duty belt does not appear to influence the prevalence rate in this population.

Adult↗
PubMed1998

Preliminary observations on the pathogenesis of experimental bovine spongiform encephalopathy (BSE): an update.

Further preliminary observations are reported of an experiment to examine the spread of infectivity and the occurrence of pathological changes in cattle exposed orally to infection with bovine spongiform encephalopathy. Calves were dosed at four months of age and clinically monitored groups were killed sequentially from two to 40 months after inoculation. Tissues were collected for bioassay, for histopathological examinations and for the detection of PrP. Previous reported observations have included the presence of infectivity in the distal ileum of cattle killed after six to 18 months, the earliest onset of clinical signs in an exposed animal after 35 months, and diagnostic histopathological changes in the brain, in association with clinical disease, after 36, 38 and 40 months. In spite of the relative inefficiency of the bioassay of scrapie-like agents across a species barrier the new observations confirm that the onset of clinical signs and pathological changes in the central nervous system (CNS) occur at approximately the same time. The earliest pathological change, the presence of abnormal PrP 32 months after inoculation, coincided with the earliest detected infectivity in the CNS and occurred shortly before there was evidence of typical spongiform changes in the brain 36 months after inoculation. Infectivity has now been demonstrated in the peripheral nervous system, in the cervical and thoracic dorsal root ganglia 32 to 40 months after inoculation and in the trigeminal ganglion 36 and 38 months after inoculation. At the time of writing evidence of infectivity in other tissues is confined to the distal ileum, not only after six to 18 months but also after 38 and 40 months, but these findings may be supplemented by the results of further mouse assays. Nevertheless, they are in general agreement with current knowledge of the pathogenesis of scrapie.

Animals↗
PubMed1998

Risk of hemolytic uremic syndrome after sporadic Escherichia coli O157:H7 infection: results of a Canadian collaborative study. Investigators of the Canadian Pediatric Kidney Disease Research Center.

OBJECTIVES: The objectives of this study were to better estimate the age-specific risks of hemolytic uremic syndrome (HUS) and hemolytic anemia after Escherichia coli O157:H7 infection among a representative cohort of both referred and nonreferred children with documented illness from the province of Alberta and to compare this with the rates in children evaluated at referral centers in the rest of Canada. STUDY DESIGN: Children with HUS or E. coli O157:H7 gastroenteritis were eligible if they were < 15 years of age. Hemoglobin, blood smear, urinalysis, and serum creatinine were obtained 8 to 10 days after the onset of diarrhea to ascertain for hemolysis, anemia, thrombocytopenia, and renal injury. Subjects were monitored for 1 month. RESULTS: From June 1991 to March 1994, HUS was diagnosed in 205 children. Of these 77% had evidence of E. coli O157:H7 infection. A further 582 children had E. coli O157:H7 gastroenteritis, of whom 18 had hemolytic anemia. The risk of HUS after E. coli O157:H7 infection in Alberta was 8.1% (95% confidence interval, 5.3 to 11.6) compared with 31.4% in referral centers in the rest of Canada. In Alberta the highest age-specific risk of HUS/hemolytic anemia was 12.9% in those < 5 years of age. CONCLUSIONS: These data will help guide clinical care and provide a basis for estimating the sample sizes required in future treatment trials for the secondary prevention of HUS.

Adolescent↗
PubMed1998

Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group.

STUDY OBJECTIVE: The benefit of Advanced Cardiac Life Support (ACLS) medications during cardiac resuscitation is uncertain. The objective of this study was to determine whether the use of these medications increased resuscitation from in-hospital cardiac arrest. METHODS: A prospective cohort of patients undergoing cardiac arrest in 1 of 5 academic hospitals was studied. Patient and arrest factors related to resuscitation outcome were recorded. We determined the association of the administration of ACLS drugs (epinephrine, atropine, bicarbonate, calcium, lidocaine, and bretylium) with survival at 1 hour after resuscitation. RESULTS: Seven hundred seventy-three patients underwent cardiac resuscitation, with 269 (34. 8%) surviving for 1 hour. Use of epinephrine, atropine, bicarbonate, calcium, and lidocaine was associated with a decreased chance of successful resuscitation (P <.001 for all except lidocaine, P <.01). While controlling for significant patient factors (age, gender, and previous cardiac or respiratory disease) and arrest factors (initial cardiac rhythm, and cause of arrest), multivariate logistic regression demonstrated a significant association between unsuccessful resuscitation and the use of epinephrine (odds ratio . 08 [95% confidence interval .04-.14]), atropine (.24 [.17-.35]), bicarbonate (.31 [.21-.44]), calcium (.32 [.18-.55]), and lidocaine (.48 [.33-.71]). Drug effects did not improve when patients were grouped by their initial cardiac rhythm. Cox proportional hazards models that controlled for significant confounders demonstrated that survivors were significantly less likely to receive epinephrine (P <. 001) or atropine (P <.001) throughout the arrest. CONCLUSION: We found no association between standard ACLS medications and improved resuscitation from in-hospital cardiac arrest. Randomized clinical trials are needed to determine whether other therapies can improve resuscitation from cardiac arrest when compared with the presently used ACLS drugs.

Aged↗
PubMed1998

The Ontario Prehospital Advanced Life Support (OPALS) Study: rationale and methodology for cardiac arrest patients.

The Ontario Prehospital Advanced Life Support Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period. The study will evaluate the incremental benefit of rapid defibrillation and prehospital Advanced Cardiac Life Support measures for cardiac arrest survival and the benefit of Advanced Life Support for patients with traumatic injuries and other critically ill prehospital patients. This article describes the OPALS study with regard to the rationale and methodology for cardiac arrest patients.

Cost-Benefit Analysis↗
PubMed1998

A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation.

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet including: detailed information about HRT benefits and risks tailored to a woman's clinical risk, and a values clarification exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, informed, clear about values, and supported in decision making. Women's values elicited in the clarification exercise were 84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids are useful in preparing women for decision making about this complex, personal issue.

Aged↗
PubMed1998

Prion protein immunohistochemical staining in the brains of monkeys with transmissible spongiform encephalopathy.

Prion protein (PrP) immunohistochemical staining of the brains of common marmosets (Callithrix jacchus) with experimental transmissible spongiform encephalopathy is described. The monkeys (n = 17) had been injected, intracerebrally, 17-49 months previously with homogenates of brain tissue taken post mortem from a cow with BSE (n = 2 monkeys), a sheep with natural scrapie (n = 2 monkeys), human cases of growth hormone related Creutzfeldt-Jakob disease (CJD) (n = 2 monkeys), sporadic CJD (n = 5 monkeys), or Gerstmann-Sträussler-Scheinker disease (GSS) (n = 4 monkeys), or from monkeys with spongiform encephalopathy resulting from injection with brain tissue from these last two cases (n = 1 monkey from each case). Only diffuse PrP-staining was seen in monkeys injected with CJD-material whereas more aggregated deposits of PrP were seen in monkeys injected with BSE-, scrapie--and GSS-brain tissue. There were no patterns of staining specific to the brains injected with BSE-material that could be used to identify the origin of that inoculum. BSE--and scrapie-injected monkey brains could be distinguished from each other because in BSE-injected monkey brain the spongiform vacuolation was largely confined to subcortical structures whereas in scrapie-injected monkey brain the spongiform vacuolation was also prominent in the neocortex. The patterns of PrP deposition differed markedly between those seen in monkey brains injected with BSE-material or CJD-material, but the patterns of PrP staining seen in monkey brains injected with BSE-material were also seen in monkey brains injected with scrapie--or GSS-material. Overall there was a correlation between the length of the incubation period and the amount of aggregated PrP-staining, but no correlation between the neuropathological picture and the clinical presentation of neurological signs.

Adult↗
PubMed1998

An assessment of clinical wound evaluation scales.

OBJECTIVE: To compare 2 clinical wound scales and to determine a minimal clinically important difference (MCID) on the visual analog cosmesis scale. METHODS: Using data from 2 previously published clinical trials, 91 lacerations and 43 surgical incisions were assessed on the 2 scales; a 100-mm visual analog scale (VAS) (0 = worst possible scar, 100 = best possible scar) and a wound evaluation scale (WES) assessing 6 clinical variables (a score of 6 is considered optimal, while a score of < or =5 suboptimal). All wound assessments on the VAS were done by 2 cosmetic surgeons who rated photographs on 2 occasions. A cohort of wounds on the WES were assessed by a second observer. The difference of the mean optimal and suboptimal VAS scores for each study was used to determine a MCID on the VAS scale. RESULTS: The VAS scale yielded intraobserver agreements of 0.93 and 0.87 (95% CI: 0.89-0.96 and 0.78-0.93) and interobserver agreements of 0.50 and 0.71 (95% CI: 0.32-0.65 and 0.52-0.84) for lacerations and incisions, respectively. Kappa coefficient measuring agreement on the WES was 0.79 (95% CI: 0.57-1.0). The mean (+/-SD) VAS scores of optimal wounds were 72 +/- 12 mm and 65 +/- 20 mm, while the mean scores of suboptimal wounds were 57 +/- 17 mm and 50 +/- 23 mm for lacerations and incisions, respectively. CONCLUSIONS: An MCID on the VAS cosmesis scale is 15 mm. Studies should be designed to have a sample size and power to detect this difference.

Cicatrix↗
PubMed1998

Emergency physicians' attitudes toward and use of clinical decision rules for radiography.

OBJECTIVES: 1) To assess Canadian emergency physicians' (EPs') use of and attitudes toward 2 radiographic clinical decision rules that have recently been developed and to identify physician characteristics associated with decision rule use; 2) to determine the use of CT head and cervical spine radiography by EPs and their beliefs about the appropriateness of expert recommendations supporting the routine use of these radiographic procedures; and 3) to determine the potential acceptance of clinical decision rules for CT scan in patients with minor head injury and cervical spine radiography in trauma patients. METHODS: A cross-sectional anonymous mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians using Dillman's Total Design Method for mail surveys. RESULTS: Of 288 eligible physicians, 232 (81%) responded. More than 95% of the respondents stated they currently used the Ottawa Ankle Rules and were willing to consider using the newly developed Ottawa Knee Rule. Physician characteristics related to frequent use of the Ottawa Ankle Rules were younger age, fewer years since graduating from medical school, part time or resident employment status, working in a hospital without a CT scanner, and believing that decision rules are not oversimplified cookbook medicine or too rigid to apply. Eighty-five percent did not agree that all patients with minor head injuries should receive a CT head scan and only 3.5% stated they always refer such patients for CT scan. Similarly, 78.5% of the respondents did not agree that all trauma patients should receive cervical spine radiography and only 13.2% said they always refer such patients for cervical spine radiography. Ninety-seven and 98% stated they would be willing to consider using well-validated decision rules for CT scan of the head and cervical spine radiography, respectively. Fifty-two percent and 67% of the respondents required the proposed CT and C-spine to be 100% sensitive for identifying serious injuries, respectively. CONCLUSIONS: Canadian EPs are generally supportive of clinical decision rules and, in particular, have very positive attitudes toward the Ottawa Ankle and Knee Rules. Furthermore, EPs disagree with recommendations for routine use of CT head and cervical spine radiography and strongly support the development of well-validated decision rules for the use of CT head and cervical spine radiography. Most EPs expected the latter rules to be 100% sensitive for acute clinically significant lesions.

Adult↗