Temporal trends in breast cancer surgery in Ontario: can one randomized trial make a difference?

OBJECTIVE

To assess the effect of a single randomized clinical trial, the National Surgical Adjuvant Breast Project (NSABP) B-06, on the surgical management of breast cancer in women.

DESIGN

Retrospective cohort study.

SETTING

All hospitals in Ontario.

PATIENTS

A consecutive sample of 37,447 women with breast cancer newly diagnosed from Jan. 1, 1980, to Dec. 31, 1989, linked to a surgical procedure record in the Ontario Cancer Registry.

MAIN OUTCOME MEASURE

The most invasive surgical procedure used within 90 days of diagnosis.

RESULTS

Unilateral breast-ablative surgery (BAS) was performed in 57.3% of the women and breast-conserving surgery (BCS) in 31.6%. The annual rate of BAS declined from 77.5% in 1980 to 44.2% in 1989 and the rate of BCS rose from 12.5% in 1980 to 43.5% in 1989. The decline was linear from 1980 to 1984 and then accelerated significantly in 1985 (p < 0.0001), after the results of the NSABP B-06 trial were published.

CONCLUSION

One randomized clinical trial can have an immediate and profound effect on medical practice.

Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country

Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies (%) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley, 3.2 vs. 95.9 for NG, and 3.9 vs. 95.2 for CT. The differences in the application of these life saving procedures between the pre-ATLS and post-ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Establishment of reliability in the evaluation of hand sensibility

Evaluation of hand sensibility using measures of threshold and tactile discrimination are standard assessment methods following nerve injury. Many of the available sensory measures for the quantification of hand sensibility lack verification of intertester reliability. Intertester reliability of vibration threshold, cutaneous pressure threshold, two-point discrimination, object identification, and texture identification was established. The intraclass correlation coefficient ranged from 0.96 to 0.99 for all variables except texture identification (r = 0.77). Comparisons were made between the sensory measures and each functional measure. The strongest correlational relationship was between two-point identification and object identification. Based on the results of this study, evaluation of hand sensibility may be attained with measurement of vibration and cutaneous pressure threshold, two-point discrimination, and object identification.

Development of a new measure of fine sensory function

With the loss of sight, the blind individual must rely on tactile senses for function, and yet assessment of hand sensibility is not routinely integrated into evaluations of the blind. The available sensory measures lack the sensitivity to differentiate higher levels of hand sensibility, and therefore, a new more sensitive measure of fine sensory function was developed. A 3 x 3 braille dot cell was developed, and pattern variation was utilized to assess higher discriminatory abilities. Thirty blind and sighted subjects were evaluated, and intertester reliability of fine sensory function (braille pattern identification) was established (r = 0.95). Comparison between braille identification and measures of threshold and innervation density revealed the strongest correlational relationship with two-point discrimination. This study supports the assessment of fine sensory function with braille pattern identification.

Task-specific physical therapy for optimization of gait recovery in acute stroke patients

A randomized controlled pilot trial was conducted to estimate the effects of early, intensive, gait-focused physical therapy on ambulatory ability in acute, stroke patients. Twenty-seven patients with middle cerebral artery infarct of thromboembolic origin confirmed by computed axial tomography scan were stratified and randomly assigned to the experimental group, to a control group that received early, intensive and conventional therapy, or to a group receiving routine conventional therapy that started later and was not intense. Assessments at entry, six weeks, and three and six months by independent evaluators permitted comparisons with reference to clinical measures of motor performance, balance, and functional capacity, and laboratory measures of gait movements. Group results at six weeks demonstrated that gait velocity was similar in the two conventional groups thereby eliminating the timing of the interventions as an important factor. At that point, gait velocity was faster in the experimental group. The difference translated into a moderate effect size of 0.58. The time dedicated to gait training but not to total therapy time was correlated (rs = 0.63) to gait velocity. This effect disappeared at three and six months after stroke. These pilot results justify planning a large trial to test the effectiveness of a therapeutic protocol that focuses on early and intense gait therapy in an effort to facilitate early ambulation following stroke.

Trauma outcome improves following the advanced trauma life support program in a developing country

Trauma outcome variables before and after the institution of the Advanced Trauma Life Support (ATLS) program were compared for the largest hospital in Trinidad and Tobago from July 1981 through December 1985 (pre-ATLS) and from January 1986 to June 1990 (post-ATLS). A total of 199 physicians were ATLS trained by June 1990. Outcome data were analyzed for all dead or severely injured patients (ISS > or = 16; n = 413 pre-ATLS and n = 400 post-ATLS). Trauma mortality decreased post-ATLS (134 of 400 vs. 279 of 413) throughout the hospital, including the ICU (13.6% post-ATLS ICU mortality vs. 55.2% pre-ATLS). The odds of dying from trauma increased with age (1.02 for each year), ISS score (1.24 for each ISS increment), and blunt injury, both pre-ATLS and post-ATLS. Post-ATLS mortality was associated with a higher ISS (31.6 vs. 28.8). Although there was a higher percentage of blunt injury pre-ATLS (84.0%) versus post-ATLS (68.3%), the mortality rates for both blunt and penetrating injuries were higher in the pre-ATLS group (19.7% pre-ATLS vs. 6.3% post-ATLS for penetrating and 76.6% pre-ATLS versus 46.2% post-ATLS for blunt). For each ISS category, mortality was greater in the pre-ATLS group (ISS > or = 24 pre-ATLS mortality 47.9% vs. 16.7% post-ATLS; ISS 25-40 pre-ATLS mortality 91.0% vs. 71.0% post-ATLS). The overall ratio of observed to expected mortality based on the MTOS data base was lower for the post-ATLS period (pre-ATLS ratio 3.16; post-ATLS ratio 1.94).(ABSTRACT TRUNCATED AT 250 WORDS)

[The Gastrointestinal Quality of Life Index. A clinical index for measuring patient status in gastroenterologic surgery]

Since the measurement of quality of life is a relevant endpoint of patient assessment, an international team of methodologists and surgeons have developed a new system-specific index. In different phases, items were collected, tested, rejected or retained and finally verified by international experts. The instrument was also validated against other generic measures, it was compared to 150 normals, tested for reproducibility with 50 stable patients and for responsiveness with 159 patients undergoing laparoscopic cholecystectomy. The product is a bilingual (German and English) questionnaire containing 36 items. Although further testing is in order, we conclude that the Gastrointestinal Quality-of-Life Index is ready to be used in clinical practice and research.

Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients

A sample of 360 severely injured patients was selected from a cohort of 8007 trauma victims followed prospectively from the time of injury to death or discharge. A case referent study was used to test the association between on-site care, total prehospital time, and level of care at the receiving hospital with short-term survival. Multiple logistic regression analyses showed that use of Advanced Life Support (ALS) at the scene was not associated with survival, whereas treatment at a level I compatible hospital was associated with a 38% reduction in the odds of dying, which approached statistical significance. Total prehospital time over 60 minutes was associated with a statistically significant adjusted relative odds of dying (OR = 3.0). The results of this study support the need for regionalization of trauma care and fail to show a benefit associated with ALS.

Determinants of preventive practices of general practitioners in Torino, Italy

We conducted a study of general practitioners in Torino, Italy, to determine their patterns of preventive practice. We examined a set of primary and secondary preventive interventions and their determinants. We explored the determinants of primary preventive interventions (antismoking and alcohol abuse counseling, counseling for prevention of accidents at home among the elderly, flu vaccination for the elderly, and counseling on contraceptive use) and cancer early detection techniques (chest x rays and sputum cytology for lung cancer; mammography, physical examination, teaching of breast self-examination, and Papanicolaou [Pap] smear for gynecological cancers). Grouping determinants in cognitive, sociodemographic, and organization factors, we found different patterns for each maneuver. Cognitive factors played an important role, but their importance varied for each intervention. We found that smoking behavior of physicians predicted antismoking counseling. Further, the availability of other primary care services is an important factor in the early detection of gynecological cancers.

Clinical and laboratory measures of postural balance in an elderly population

The objective of this cross-sectional study was to compare scores on the Balance Scale with laboratory measures of postural sway and other clinical measures of balance and mobility. Thirty-one elderly subjects were assessed on the clinical measures and the laboratory tests of postural sway while standing still and in response to pseudorandom movements of the platform. The average correlation between the Balance Scale and the spontaneous sway measures was -.55. It was slightly lower (r = -.38) for the same parameters measured during the pseudorandom tests. There were high correlations between the Balance Scale and the Balance Sub-Scale developed by Tinetti (r = .91), Barthel Mobility sub-scale (r = .67), and timed "Up and Go" (r = -.76). The Balance Scale was the most efficient measure (effect size > 1) to statistically discriminate between subjects according to their use of each type of mobility aide (walker, cane, no aids). These data contribute to existing information on the performance of the Balance Scale and supports the validity of the Balance Scale in this geriatric population.

Cytochemical detection of superoxide in cerebral inflammation and ischemia in vivo

We used a cytochemical technique for the detection of superoxide in cerebral inflammation and ischemia-reperfusion in anesthetized cats. The technique is based on the oxidation of Mn2+ to Mn3+ by superoxide; Mn3+, in turn, oxidizes diaminobenzidine. The oxidized diaminobenzidine forms an osmiophilic electron-dense product that is detected by electron microscopy. The reagents, manganese chloride (2 mM) and diaminobenzidine (2 mg/ml), were placed topically on the brain surface of anesthetized cats equipped with cranial windows. Inflammation was induced by topical carrageenan with or without phorbol 12-myristate 13-acetate to activate leukocytes. In inflammation, superoxide was detected in the plasma membrane and in the phagocytic vacuoles of leukocytes. In ischemia-reperfusion, superoxide was identified in the meninges in association with blood vessels. It was located primarily in the extracellular space and occasionally in endothelial and vascular smooth muscle cells. In both inflammation and ischemia, the reaction product was eliminated by superoxide dismutase or by the omission of either manganese or diaminobenzidine. It was unaffected by sodium azide, which inhibits peroxidases. No superoxide was detected in the brain parenchyma. The findings confirm the generation of superoxide is cerebral ischemia-reperfusion and show that it is produced in cerebral vessels.

Standardized mortality ratio analysis on a sample of severely injured patients from a large Canadian city without regionalized trauma care

Flora's Z statistic and standardized mortality ratios (SMRs) as indicators of excess mortality were calculated for a sample of 355 patients with major trauma. A statistically significant overall excess mortality was observed in this sample (Z = 6.77, SMR = 1.81, p less than 0.05). Advanced life support provided by physicians at the scene (MD-ALS) was not associated with reduced excess mortality. A significant trend toward lower excess mortality was associated with a higher level of trauma care at the receiving hospital (p less than 0.05). Total prehospital time over 60 minutes was associated with a significant increase in excess mortality (p less than 0.001). These results support regionalization of trauma care and failed to show any benefit associated with MD-ALS.

Measuring balance in the elderly: validation of an instrument

This study assessed the validity of the Balance Scale by examining: how Scale scores related to clinical judgements and self-perceptions of balance, laboratory measures of postural sway and external criteria reflecting balancing ability; if scores could predict falls in the elderly; and how they related to motor and functional performance in stroke patients. Elderly residents (N = 113) were assessed for functional performance and balance regularly over a nine-month period. Occurrence of falls was monitored for a year. Acute stroke patients (N = 70) were periodically rated for functional independence, motor performance and balance for over three months. Thirty-one elderly subjects were assessed by clinical and laboratory indicators reflecting balancing ability. The Scale correlated moderately with caregiver ratings, self-ratings and laboratory measures of sway. Differences in mean Scale scores were consistent with the use of mobility aids by elderly residents and differentiated stroke patients by location of follow-up. Balance scores predicted the occurrence of multiple falls among elderly residents and were strongly correlated with functional and motor performance in stroke patients.

Testing various methods of introducing health charts into medical records in family medicine units

OBJECTIVE

To test three methods of introducing health charts into the medical records of six family medicine units.

DESIGN

Quasi-experiment.

PARTICIPANTS

The staff physicians and family medicine residents in all six units and the nurses in two units.

INTERVENTIONS

Group 1 (minimal intervention): health charts, a user's guide and one training session. Group 2 (intermediate intervention): same intervention as for group 1 plus two feedback sessions at 3 and 6 months. Group 3 (maximum intervention): same intervention as for group 2 plus promotion of the team concept (nurses were included). The intervention phase lasted from September 1987 to August 1988.

OUTCOME MEASURES

The frequency with which the health charts were used, the item scores of each preventive care activity and the overall unit scores. Data were gathered through chart audits at baseline and at the end of the intervention phase.

RESULTS

The frequency with which the health charts were used varied from 3.9% to 26.9%. The greatest increases in item scores were observed in the use of mammography (20.0%), counselling on lifestyle (19.4%) and breast examination (17.2%). Although the overall improvement in the unit scores was statistically significant (p less than 0.05) the hypothesis of an increasing gradient of effect across the three intervention groups could not be tested because of the variation in scores across the units.

CONCLUSION

Health charts and other similar tools are useful; however, they are not sufficient to change practice behaviours. The support of a "champion" on the health care team might well be a determining factor of success for the delivery of preventive services in primary care practice.

Arthritis impact measurement scales: reliability of a French version and validity in adult Still's disease

The Arthritis Impact Measurement Scales (AIMS) questionnaire was administered to 57 patients with adult Still's disease (ASD) and 104 controls. Six of the 9 scales were consistent for both groups (Cronbach's alpha greater than or equal to 0.70). Two scales, Mobility and Dexterity, were consistent for ASD only (alpha greater than or equal to 0.70). The reliability of a French version of the AIMS was similar to the standard AIMS. Of the 13 associations evaluating criterion related validity of the AIMS in ASD, 11 were statistically significant. We conclude that the French and standard AIMS are comparable and that this questionnaire is reliable and valid for assessing outcome in ASD.

Examining outcome measures in a clinical study of stroke

We investigated the relation between outcome and sample size for six selected stroke outcome measures to assist investigators in selecting end points for stroke studies. Data from a clinical trial of 167 stroke patients assessed shortly after admission to the hospital and 5 weeks later provided information on clinical, motor, and functional outcomes measured using a neurologic status scale, a stroke severity scale, the Fugl-Meyer Scale, the Barthel Index, and the activities of daily living and cognition subscales of the Level of Rehabilitation Scale. Data were examined using Pearson correlation coefficients and power analyses. All measures were significantly correlated. There was also substantial congruency between the subscales of a measure and its total score. The measures had variable efficiencies; the Barthel Index was the most efficient and therefore required the fewest subjects to identify a significant effect. These data suggest that careful consideration must be given to the choice of stroke outcome measures in terms of their numbers, interrelationships, and statistical properties, as these factors have important implications for the design, analysis, and conduct of clinical stroke studies.

Determinants of preventive practices in fee-for-service primary care

A study of primary care physicians was conducted in the provinces of Quebec and New Brunswick, Canada, to ascertain their patterns of preventive practice with respect to cancer in four anatomic sites: breast, cervix, colon-rectum, and lung. The determinants of preventive practices among 552 fee-for-service physicians in both provinces are explored. Scales were created for the practice behaviors related to each type of cancer (dependent variables) and for knowledge and belief (independent variables). The content of these scales was delineated through factor analysis and their reliability assessed using Cronbach's alpha. Other variables were considered in the analysis, including continuing education activities, perceived barriers to prevention, and other sociodemographic and professional variables. Bivariate analysis and multivariate techniques were used. The explanatory factors were regrouped into cognitive, sociodemographic, and organizational determinants. Particular patterns were delineated for each cancer type. In a fee-for-service reimbursement setting without specific incentives for preventive practices, the creation of favorable organizational environments and the conveying of agreed-upon information to physicians are important ways of enhancing the integration of preventive activities into clinical practice. Identification of the sociodemographic determinants of preventive practices reveals the complexity of physicians' behaviors.

Measuring the impact of trauma care on survival: rates of preventable death, effectiveness, and efficacy

This paper focuses on the appropriateness of outcome measures to evaluate trauma care. The preventable death rate (PDR), based on the study of deceased patients only, has been the traditional measure of the impact of trauma care on improving the survival of patients with severe trauma. Another measure frequently used in other ares of evaluation research is the effectiveness rate--i.e. the survival rate in the total population of severe trauma patients. Because both the PDR and the effectiveness rate vary with the proportion of patients who would die even under conditions of optimal care, these two measures can be misleading. We illustrate their inadequacy by using published data on the impact of regionalization of trauma care. We propose the use of a third outcome measure of the impact of trauma care on survival, the efficacy rate--i.e. the survival rate among severe trauma patients with a potential for survival. Evaluation of trauma care should also measure outcomes other than survival and need not be restricted to patients with the most severe trauma. Evaluation of trauma care therefore requires outcome measures, such as the efficacy rate, which are based on the population at risk of manifesting the outcome of interest.

Decline of acute myocardial infarction death rates not due to cause of death coding

The recent decline in coronary heart disease (CHD) mortality has been attributed to reduction in risk factors, improved management and the possibility of statistical artifacts. The purpose of this study is to assess the impact of geographic and time variation in the coding of cause of death from death certificates into ICD codes upon CHD mortality rates in Canada. Equal samples of death certificates were recoded for Nova Scotia and Saskatchewan for each of the years 1970 and 1984: 1) a first set of 1,600 death certificates originally coded as acute myocardial infarction (AMI) and 2) a second set of 800 death certificates from all causes of death. The coding error rates increased with age and with the number of contributing and underlying causes of death reported on the death certificates. The net effect of false positive and false negative AMI codes on death certificates did not vary significantly by province or year. Thus, variation of death certificate coding over time and geographic regions do not contribute toward the explanation of the AMI mortality rate decline.