Evaluation of factors influencing confidence and trust in the patient-physician relationship: a survey of patient in a hand clinic.

OBJECTIVES: The purpose of this study was to identify the skills found most important to gain patient's trust from a patient's perspective. METHODS: One hundred and twenty-two patients were surveyed prospectively using a questionnaire assessing professionalism, physical environment, verbal and non-verbal communication skills. Factors required to establish a trusting patient-surgeon relationship were ranked in order of importance before and after initial consultation with a surgeon in a hand surgery clinic model. RESULTS: No significant relationship was identified between gender, age, education or income, and answers provided by respondents. Technical ability, verbal communication skills and respect of patient's autonomy by the physician were found most important. CONCLUSION: The visit with the surgeon significantly affected the ranking of some of the skills deemed important. Patients view respect of autonomy and verbal communication skills as the most important attributes when developing trust and confidence in a surgeon, followed by technical proficiency.

Mechanical failure of a Fogarty catheter in a microsurgical procedure: a case report.

Although microvascular free-tissue transfer has become a reliable reconstructive method, vascular compromise of the flap necessitating surgical exploration and attempts at flap salvage commonly occurs. Thrombectomy using Fogarty vascular catheters can be used in the setting of vascular pedicle thrombosis. However, this is not without potential complications. The following report describes a case in which the use of a Fogarty vascular catheter during a thrombectomy for microsurgical flap salvage resulted in complete separation of the balloon from the catheter.

Comparative analysis between scientific and the media communication following facial transplantation.

PURPOSE: Our aim was to analyze the communications about three outstanding medical reports. Was there any difference in the reports of the three allografts? Was there a correlation between the media and the scientific world? METHODS: The Internet sites of three major newspapers were used for the media database. Those results were compared with PubMed between 2005 and 2007 using these key words: "facial graft," "facial allograft," "composite tissue allograft," and names of surgeons of the graft. We did a comparative analysis using a word processor and a quality analysis software. RESULTS: We analyzed 51 articles from the media and six from the PubMed database. In PubMed, 100% of the articles were on the first graft and respected the privacy of the patient compared to 67% of the media who unveiled the identity. CONCLUSION: The communication following a medical premiere depends on the team, which performes the act. We observed a major difference between the three cases. Ethical considerations are different for the media and for scientists. The communication management of a medical premiere takes preparation and evaluation.

Reducing patient discomfort during digital blockade: The subcutaneous single injection digital block - A simple, safe and fast procedure.

BACKGROUND: Regional anesthesia of a single finger is commonly achieved by the traditional ring block, which requires at least two painful injections in the digit. Single injection digital block techniques have been described to avoid this problem. Among these, the subcutaneous technique described by Harbison appears to be safe and to allow most procedures to be carried out with good tolerance. OBJECTIVES: A prospective study was designed to evaluate the results of the subcutaneous technique in terms of patient tolerance, distribution of anesthesia and efficiency. METHODS: All blocks were performed by a single investigator. A visual analog scale was used to evaluate pain associated with the injection. Prick testing was used to evaluate the quality of anesthesia at the volar and dorsal aspects of the phalanxes. Tolerance to the surgical procedure and the need for additional injections were also recorded. RESULTS: This technique allowed surgery to be performed without complementary injection most of the time and was very well tolerated. The dorsum of the proximal phalanx, however, was unpredictably included in the anesthetized territory. CONCLUSION: The subcutaneous single injection digital block is safe, efficient and easy to perform. It allows the treatment of all conditions on the volar aspect of the finger and on the dorsal aspect of the distal and middle phalanxes. For surgery on the dorsal aspect of the proximal phalanx, a combined single injection technique or a supplementary dorsal block should be used.

CONTEXTE: L'anesthésie régionale d'un seul doigt se réalise généralement par le traditionnel bloc en bague, qui exige au moins deux injections douloureuses. Il semblerait que les techniques d'anesthésie à une seule injection résoudrait le problème. Parmi celles-ci, la technique d'injection sous-cutanée décrite par Harbison serait sûre tout en permettant à la plupart des interventions d'être bien tolérées. OBJECTIF: Étude prospective visant à évaluer les résultats de la technique d'injection sous-cutanée au regard de la tolérance, de l'étendue de l'anesthésie et de son efficacité. MÉTHODE: Toutes les anesthésies en bloc ont été effectuées par le même chercheur. L'intensité de la douleur associée à l'injection a été évaluée à l'aide d'une échelle visuelle analogue. Un test par piqûre a servi à évaluer la qualité de l'anesthésie sur les faces antérieure et postérieure des phalanges. La tolérance à l'intervention chirurgicale et le besoin d'injections supplémentaires ont également été notés. RÉSULTATS: Dans la plupart des cas, l'intervention a été très bien tolérée, sans recours à une injection supplémentaire d'anesthésique. Toutefois, le dos de la phalange proximale était compris de façon imprévisible dans le territoire anesthésié. CONCLUSION: L'anesthésie du doigt par une seule injection sous-cutanée s'avère simple, sûre et efficace. Elle permet de traiter tous les troubles sur la face antérieure du doigt ou sur la face postérieure des phalanges médianes et distales. Quant aux interventions pratiquées sur la face postérieure des phalanges proximales, il faudrait recourir à une technique mixte à une seule injection ou à une anesthésie complémentaire du dos du doigt.

Adhesive strips: a simple and inexpensive trick for finger holding in hand surgery.

Many finger holding devices have been developed to retract digits and provide exposure during hand surgery. We describe a simple, and cheap trick to keep fingers out of the way using adhesive strips that has proven efficient and helpful.

Trauma care regionalization: a process-outcome evaluation.

BACKGROUND: Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients. METHODS: This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III). RESULTS: A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers. CONCLUSION: This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Ineffectiveness of on-site intravenous lines: is prehospital time the culprit?

The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.

Predictive validity and internal consistency of the pre-hospital index measured on-site by physicians.

Physiological measures of injury are used as triage tools to identify patients that require treatment in trauma centres. The Pre-Hospital Index (PHI) is based on systolic blood pressure, pulse, respiratory rate, (level of) consciousness, and presence of penetrating injury. The present study evaluated the validity and internal consistency of the PHI. The study was based on 628 patients assessed by physicians at the scene. Mean age was 38.7 years (SD = 24.8), and 65% were male. Motor vehicle collisions caused the injury for 45%. The majority had head/neck (56%) and extremity (45%) injuries. Mean PHI was 4.62 (SD = 5.77), 40% had a PHI of zero, 6% between 1 and 3, 32% between 4 and 7, and 21% greater than 7. The associations between PHI and rates of hospital admission, surgery, ICU treatment, mortality, duration of hospitalization, and length of ICU stay were significant (p < 0.001). A total of 260 (41.4%) patients had major trauma requiring treatment at a trauma centre. A PHI > 3 had 83% sensitivity and 67% specificity for identifying these patients. Internal consistency of the PHI variables was above the acceptable limits. This study has shown that the PHI is a valid and reliable physiological measure of injury severity and field triage tool.

Preventable death evaluation of the appropriateness of the on-site trauma care provided by Urgences-Santé physicians.

The study is based on 44 preventable deaths occurring in a cohort of 360 patients with major trauma. These cases were reviewed by a committee of nine experts. The mean Injury Severity Score (ISS) was 28, and most cases had injuries to the head/neck (68%) and chest (64%). The mean (+/- SD) observed prehospital times, and those considered the maximum allowable by the committee, were 40.6 +/- 12.0 minutes for head/neck injuries and 23.9 +/- 12.2 minutes for chest injuries (p < 0.05). Intravenous (i.v.) lines were started in 38 (86%) of the patients. The committee classified this procedure as harmful for 16 (42%) and neutral for 19 (50%). Among the 18 (46%) that were intubated, this intervention was considered harmful for 17% and neutral for 39%. In two of the three patients for whom a pneumatic antishock garment was applied, this procedure was considered harmful. Of the 34 patients that required direct transport at a level I trauma center, 50% were transferred to such a hospital. These results show significant prehospital delays and high rates of inappropriate IV line initiation and intubation in trauma patients receiving on-site care by physicians. We conclude that prehospital care protocols for trauma patients should emphasize prompt transport and specific on-site care algorithms.

Trauma center designation: initial impact on trauma-related mortality.

The movement towards trauma care regionalization in Québec was initiated in 1990, with formal designation of three level I trauma centers in 1993. The purpose of this study is to evaluate the impact of trauma center designation on mortality. The study design is that of a two-cohort study, one assembled during 1987 when designation was not in effect, and the other during the first 5 months of designation. The study focuses on patients that fulfilled the following criteria: i) arrived alive at the hospital, and ii) were admitted. The outcome measures are adjusted mortality, and excess mortality as measured by the TRISS methodology. A total of 158 patients treated in 1987, and 288 treated in 1993, were identified. The mean age of the patients treated in 1993 was significantly higher (40.0, +/- 18.1), when compared with the 1987 group (30.9 +/- 18.1; p < 0.001). Patients in the 1987 cohort had a significantly higher proportion of injuries caused by stabbing (p = 0.02), and a significantly lower proportion caused by falls (p = 0.003). The 1987 cohort had a higher rate of abdominal injuries (p = 0.0001), and external injuries (p = 0.0001), and a significantly lower rate of head or neck injuries (p = 0.003), and injuries to the extremities (p = 0.0001). The mean Injury Severity Score (ISS) for the 1987 cohort was 14.96 (+/- 12.36), and 15.49 (+/- 11.61) in 1993 (p = 0.65). The crude mortality rate was 20% for 1987, and 10% for 1993. The crude odds ratio for mortality in 1987 was 2.10 with 95% confidence intervals between 1.22 and 3.62 (p = 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Preventable death classification: interrater reliability and comparison with ISS-based survival probability estimates.

The purpose of the study was to compare the injury-related threat to survival estimated by the Injury Severity Score (ISS) and a committee of experts. The charts of 116 (73 fatalities and 43 survivors) patients with severe injuries were reviewed. A committee of nine clinicians classified each case as survivable, potentially survivable, and nonsurvivable based on anatomical descriptors, mechanism of injury, and patient's age. Majority was used to determine the final committee classification. Based on the ISS values, cases were classified as survivable (9-24), potentially survivable (25-49), and nonsurvivable (> 49). The results showed poor interrater reliability among the nine clinicians with an overall intraclass correlation coefficient of 0.43. The ISS-based classification had high agreement with the final committee classification (overall weighted kappa = 0.71). Lower agreement was observed for falls and with increasing number of injuries. This study has demonstrated no additional benefit for using a committee to classify injury severity on the basis of anatomical damage over applying ISS-based survival probabilities. The continued use of the ISS is supported.

Determinants of on-scene time in injured patients treated by physicians at the site.

INTRODUCTION: The controversy surrounding the use of advanced life support (ALS) for the pre-hospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care. In Montreal, Québec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene. HYPOTHESIS: The use of on-site ALS by physicians is associated with a significant increase in scene time. METHODS: A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were used to analyze the data. RESULTS: Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean = 5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (> 20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009). CONCLUSION: This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with severe injuries.

Preferential mitogenic activity for myoblast-like cells can be extracted from uterine leiomyoma tissues.

The presence of mitogen(s) in leiomyoma extracts stimulating cells with the fibroblast, myoblast, and osteoblast phenotype was documented. Mitogenic activity in leiomyoma extracts was acid stable and sensitive to tryptic digestion. Reverse-phase high-performance liquid chromatography successfully separated mitogen(s) with preferential activity for myoblast cells from mitogens with a broad type of cell specificity and from inhibitors. This leiomyoma-derived preferential activity for myoblasts was absent in identically treated myometrial and endometrial extracts. This suggests that leiomyoma-derived substances with preferential growth factor activity for myoblast-like cells may play a role in the pathophysiologic characteristics of uterine leiomyomas.