Moishe Liberman

Advanced or basic life support for trauma: meta-analysis and critical review of the literature.

BACKGROUNDnThe question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversynnnMETHODSnA total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems.nnnRESULTSnSix studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92.nnnCONCLUSIONnThe aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach.

The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients

Background: The treatment of obesity and related comorbidities are significant financial burdens and sources of resource expenditure. This study was conducted in order to assess the impact of weight-reduction surgery on health-related costs. Methods: This was an observational two-cohort study. The treatment cohort included patients having undergone weight-reduction (bariatric) surgery at the McGill University Health Centre (MUHC) between 1986 and 2002. The control group included age and gender matched obese patients who had not undergone weight-reduction surgery from the Quebec provincial health insurance database (RAMQ). The cohorts were followed for a maximum of 5 years from inception. The primary outcome measure was overall direct healthcare costs. Secondary outcomes included cost analysis by diagnostic category for the treatment of new medical conditions following cohort inception. Results: The cohorts were well-matched for age, gender and duration of follow-up. Patients having undergone bariatric surgery had significant reductions in mean percent initial excess weight loss (67.1%, P <0.001) and in percent change in initial body mass index (34.6%, P <0.001). Bariatric surgery patients had higher total costs for hospitalizations (per 1,000 patients) in the first year following cohort inception (surgery cohort = CDN

The New Injury Severity Score: a more accurate predictor of in-hospital mortality than the Injury Severity Score.

12,461,938; control cohort = CDN

Multicenter Canadian Study of Prehospital Trauma Care

3,609,680). At 5 years after cohort inception, average cumulative costs for operated patients were CDN

Breast cancer diagnosis by scintimammography: a meta-analysis and review of the literature

19,516,667 versus CDN

Implementation of a trauma care system: Evolution through evaluation

25,264,608, for an absolute difference of almost CDN

Cardiopulmonary resuscitation: errors made by pre-hospital emergency medical personnel

6,000,000 per 1,000 patients. Conclusion: Weight-reduction surgery in morbidly obese patients produces effective weight loss and decreases long-term direct health-care costs. The initial costs of surgery can be amortized over 3.5 years.

Assessment of mortality in older trauma patients sustaining injuries from falls or motor vehicle collisions treated in regional level I trauma centers.

OBJECTIVEnThe purpose of this study was to determine whether the New Injury Severity Score (NISS) is a better predictor of mortality than the Injury Severity Score (ISS) in general and in subgroups according to age, penetrating trauma, and body region injured.nnnMETHODSnThe study population consisted of 24,263 patients from three urban Level I trauma centers in the province of Quebec, Canada. Discrimination and calibration of NISS and ISS models were compared using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics.nnnRESULTSnNISS showed better discrimination than ISS (area under the ROC curve = 0.827 vs. 0.819; p = 0.0006) and improved calibration (Hosmer-Leme-show = 62 vs. 112). The advantage of the NISS over the ISS was particularly evident among patients with head/neck injuries (area under the ROC curve = 0.819 vs. 0.784; p < 0.0001; Hosmer-Lemeshow = 59 vs. 350).nnnCONCLUSIONnThe NISS is a more accurate predictor of in-hospital death than the ISS and should be chosen over the ISS for case-mix control in trauma research, especially in certain subpopulations such as head/neck-injured patients.

The Trauma Risk Adjustment Model: A New Model for Evaluating Trauma Care

ObjectiveTo evaluate whether the type of on-site care a trauma patient receives affects outcome. Summary Background DataThe controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients. MethodsThis prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge. ResultsThe overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%. ConclusionsIn urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients.

Using Information on Preexisting Conditions to Predict Mortality From Traumatic Injury

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.