INTRODUCTION:The reliability, minimal detectable change (MDC), and construct validity of the evidence-based practice confidence (EPIC) scale were evaluated among physical therapists (PTs) in clinical practice.METHODS:A longitudinal mail survey was conducted. Internal consistency and test-retest reliability were estimated using Cronbach's alpha and the intraclass correlation coefficient (ICC), respectively. The ICC was used to compute the MDC. We evaluated construct validity by testing hypotheses that EPIC scores would be positively associated with education level and frequency of searching, reading, and using research literature in clinical decision making.RESULTS:At baseline, 275 PTs completed the EPIC scale and validity questionnaire and 187 completed the scale at retest (mean retest interval = 16 days). Internal consistency was 0.89 (95% confidence interval 0.86 to 0.91; N = 275). The ICC for test-retest reliability was 0.89 (95% confidence interval 0.85 to 0.91; N = 187). The MDC95 was 4.1 percentage points meaning that a change in an individual's score must be greater than 4.1 percentage points to exceed the limits of measurement error. The mean EPIC score was significantly higher among PTs holding a Masters or doctoral degree compared to those holding a bachelor's degree or diploma, and among PTs reporting searching online, reading, and using the research literature in clinical decision making 6 or more times compared to 0 to 5 times in a typical month.DISCUSSION:Results provide evidence of excellent test-retest reliability and acceptable construct validity and minimal measurement error on repeated administration of the EPIC scale. The scale is recommended for use among PTs in clinical practice. Validation of the EPIC scale in other health professional groups is warranted.

We wish to thank the author who identified an error in the formula we used for computing minimal detectable change (MDC) of the evidence-based practice confidence (EPIC) scale in our article recently published in JCEHP.1 As the author who critiqued our article points out, the correct formula for computing MDC at the 95% confidence level is MDC95 = 1.96 ×( √ 2)× SEM. Using the correct formula, the MDC95 of the EPIC scale is 6.1 percentage points, not 4.1 as we reported. The formula is correct in the reference we cited.2 We take full responsibility for the error. This correction does not change our interpretation of the MDC. We consider the corrected MDC95 as small, as it represents less than a 1-category change on the itemlevel response scale. At the 90% confidence level, also considered acceptable,2 the MDC90 is 5.1 percentage points

Background: The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures.Methods: We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] >= 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and chi(2) tests, followed by logistic regression analysis.Results: Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12.9%; overall mortality 15.1%). The laparotomy group had higher mean ISS (36.9 v. 24.9), higher mean abbreviated injury scores (AIS) for the abdomen (2.6 v. 0.9) and chest (3.4 v. 1.6), lower mean initial hemoglobin levels (105.2 v. 127.0 g/L), higher mean crystalloid (4249 v. 3436 mL) and blood transfusion volumes over 4 hours (12.1 v. 3.9 units), more frequent hypotension (44.6 v. 18.0%) and a higher percentage of positive CT scans (67.9% v. 28.4%) and FAST examination results (42.9% v. 3.3%) than the nonlaparotomy group. Age (mean 53.7 v. 41.5 yr); ISS (mean 39.0 v. 24.4); AIS for the head (mean 3.2 v. 1.7), abdomen (mean 1.6 v. 1.1), chest (mean 2.7 v. 1.8) and pelvis (mean 3.1 v. 2.6); crystalloid (mean 5157.3 v. 3266.4 mL) and blood transfusion volumes over 4 hours (mean 13.1 v. 3.7) and initial hypotension (61% v. 14.8%) were all greater among patients who died than those who survived. Mean initial hemoglobin levels were lower among patients who died than among those who survived (111.1 v. 126.2 g/L). Age, the AIS for the head, initial hypotension and low initial hemoglobin levels were highly predictive of mortality, whereas low initial hemoglobin levels, a positive FAST examination and high AIS for the abdomen and chest were all highly predictive of laparotomy.Conclusion: Among the polytrauma patients with pelvic fractures, 14.3% underwent laparotomy, and mortality was higher among these patients than among those who did not have the procedure. The predictors of laparotomy and mortality are similar to those anticipated in patients without pelvic fractures.

Background. The use of simulation as a teaching adjunct in Advanced Trauma Life Support (ATLS) has not undergone rigorous psychometric testing. We hypothesized that an advanced, computer-controlled human patient simulator (HPS) would be a useful adjunct to the ATLS shock skills station.Materials and methods. Forty-four PGY-1 residents enrolled in ATLS courses were randomized into control (CTL) and experimental (EXP) groups. All students took a shock-specific pre- and post-test multiple choice question examination (MCQE). The EXP group used the HPS in the shock skills station; the CTL group was taught in a traditional manner. All students participated in an experimental, shock-specific objective structured clinical examination (OSCE) session at the end and had their performance evaluated. The EXP group was asked to evaluate the teaching effectiveness of the shock skills station.Results. There were no statistically significant differences between the EXP and CTL groups with respect to the pre- and post-test MCQE or the change in scores. The groups were similar in their overall performance during the shock-specific OSCE. The EXP and CTL groups were equivalent with respect to shock recognition, identification of the type of shock, and ability to select the correct treatment plan. The shock skills station was rated from very good to excellent in 91% of the EXP group versus 63% in the CTL group. The EXP group rated the simulator most helpful in learning to analyze data from the monitors.Conclusions. Use of an advanced HPS during the ATLS shock skills station was equivalent to traditional teaching scenarios based on psychometric testing. Students subjectively preferred the simulator as a teaching tool and found it most useful in learning how to integrate data from hemodynamic monitors into clinical decision making. (C) 2007 Elsevier Inc. All rights reserved.

BACKGROUND Today more children with birth defects survive early childhood because of improved medical care; however, little information is available about patterns of long-term mortality and survival in this population. In particular, it is not clear whether other birth characteristics, apart from birth defects, have any role in their mortality. METHODS Two large cohorts of children with and without birth defects were followed for up to 17 years. More than 45,000 children with birth defects, and 45,000 matched children without birth defects born in Ontario between 1979 and 1986 were followed. Throughout the study period long-term survival rates and the risk of death were compared between the 2 cohorts. Birth characteristics were also examined to determine their effect on the risk of death. RESULTS During the study the deaths of 3620 and 301 children with and without birth defects, respectively, were recorded, indicating that those with birth defects had a 13 times higher rate of mortality (relative risk [RR], 12.9, 95% confidence interval [CI], 12.1-13.7). Mortality rates in the birth-defects cohort remained higher even after 10-15 years. In both groups children of low gestational age and low birth weight had a higher risk of death. There was a strong dose-response relationship between the number of defects and the risk of death. CONCLUSIONS Children born with abnormalities face many challenges throughout their lifetimes. If they survive the high mortality risk of the first year of life, they still have to face the considerably higher risk of death in the years to come. In addition to birth defects, other birth characteristics play an independent role in their mortality. These indicators could be used to identify high-risk children.

BACKGROUND:We compared base trauma knowledge and the impact of the Trauma Evaluation and Management (TEAM) program among senior medical students in seven countries. METHODS:We compared pre- and post-TEAM multiple choice question scores of fourth-year students in Jamaica (n = 32), Trinidad (n = 32), Costa Rica (n = 64), Australia (n = 35), United Arab Emirates (n = 68), Toronto (n = 29) and Pennsylvania (n = 34). Means and degree of improvement were compared by analysis of variance (p < 0.05 for statistical significance). Percentage pass (based on 70% or 60% pass mark), student's perception of instruction level, and grading of TEAM (based on the percentage of students grading 1-5 for each category) were assessed by chi2 analysis. [table: see text]. RESULTS:Only 31.4% of students achieved the borderline pass mark of 60%, and 5.4% achieved a clear pass mark of 70%. The performance before and after TEAM was quite variable among medical schools. A grade of > or = 4 was assigned by 74% to 100% for objectives, knowledge improvement, satisfaction, and recommending TEAM for the curriculum. TEAM was rated "just right" by 70.3% to 92.7%, "too simple" by 1.6% to 21.6%, and "too advanced" by 3.3% to 13.5% of students. CONCLUSION:Base trauma knowledge in these students, though variable, was generally very low and improved with TEAM. Our data suggest a need for greater undergraduate emphasis in trauma education.

BACKGROUND:The examination of specific characteristics of neoplasms diagnosed in children have suggested that a significant proportion can be attributed to a genetic mutation or genetic predisposition. Although the study of a genetic predisposition to cancer in children remains in the early stages, congenital abnormalities could provide essential information for mapping predisposing lesions in children with cancer.METHODS:In the current study, 2 large cohorts of children with and without congenital abnormalities were followed for the occurrence of cancer and death up to 18 years. Through this study, the risk of developing cancer by age at diagnosis, effects of birth characteristics on cancer risk, and possible associations between specific anomalies and tumor types were examined.RESULTS:Based on the follow-up of 90,400 children, the risk of developing cancer during the first year of life was found to be nearly 6 times higher in children with anomalies (rate ratio [RR] of 5.8; 95% confidence interval [95% CI], 3.7-9.1). Children with birth defects were found to be at a higher risk for developing leukemia (RR of 2.7; 95% CI, 2.1-3.6), tumors of the central nervous system (RR of 2.5; 95% CI, 1.8-3.4), sympathetic nervous system tumors (RR of 2.2; 95% CI, 1.4-3.4), and soft tissue sarcomas (RR of 1.9; 95% CI, 1.0-3.5). Among children with birth defects, children with Down syndrome, nervous system anomalies, and anomalies of the urinary system had the highest incidence rates of cancer. In the presence of birth defects, other factors such as birth weight, gestational age, age of the mother, and birth order were not found to be associated significantly with the risk of cancer.CONCLUSIONS:The significant relative risks found in the current study provided evidence of links between the presence of abnormalities and the development of cancer. Some "cancer-prone" abnormalities were identified in the current study. Such anomalies may be markers of other exposures or processes that increase the risk of developing cancer.

BACKGROUND:There is little available information regarding the effectiveness of arthroscopic knee débridement for the treatment of arthritis. The purpose of this study was to evaluate patterns of utilization of arthroscopic knee débridement and outcomes following that procedure for the treatment of degenerative arthritis in persons fifty years of age or older in the Province of Ontario. METHODS:All patients fifty years of age or older who underwent elective arthroscopic knee débridement for the treatment of degenerative arthritis between 1992 and 1996 were identified from administrative data sets. Surgical complications and subsequent knee replacements were noted. Population rates were compared across the sixteen District Health Council regions within Ontario. Outcomes were modeled as a function of patient age, gender, and comorbidity with use of multivariate regression analysis. RESULTS:We identified 14,391 eligible unilateral arthroscopic knee débridement procedures. There was a threefold difference in the population rate of arthroscopic débridement across geographic regions. Overall, 1330 (9.2%) of all patients required total knee arthroplasty within one year after the débridement. Of the 6212 patients with a minimum three-year follow-up, 1146 (18.4%) had undergone total knee replacement within three years following the débridement. Patients who were at least seventy years of age were 4.7 times more likely to have total knee arthroplasty within one year after the débridement than were those less than sixty years of age (19.0% compared with 4.0%; p < 0.05). Patients sixty years of age or older were more likely to have an early total knee replacement (within one year after the débridement) in District Health Council regions where the population rates of arthroscopic knee débridement were higher (p = 0.04). CONCLUSIONS:The higher rates of early total knee arthroplasty and the significant relationship between rates of early total knee arthroplasty and rates of utilization suggest that arthroscopic débridement for the treatment of osteoarthritis of the knee may be overutilized in elderly patients. Important clinical issues such as patient preference, risk perception, and functional outcome cannot be addressed just with the administrative data used for this study.

BACKGROUND:We assessed the effect of trauma volume on skills attrition among physicians completing the advance trauma life support (ATLS) course. METHODS:Cognitive (40 item multiple choice question [MCQ] examination) and clinical (4 objective structured clinical examinations [OSCE] trauma stations) performances were compared among physicians who completed the ATLS course, subdividing them into groups treating more than 50 and fewer than 50 trauma patients per year. Both groups had 12 physicians from six periods (n = 144) related to time of course completion: immediate (0), 6 months, 2 years, 4 years, 6 years, and 8 years after ATLS. OSCE scores (maximum standardized: 20), the degree of adherence to priorities (priority score: range 1 to 7), the degree of organized approach (approach score: range from 1 to 5) were compared. RESULTS:The mean precourse MCQ scores (59.4% to 62.4%) were similar for both groups. Immediate and progressive cognitive skill attrition and detailed clinical skill attrition were worse in the low volume group. Global skills (organized approach and adherence to priorities) were preserved similarly for at least 8 years in all groups. CONCLUSIONS:Our data suggest that trauma volume affects trauma skills attrition.

Background: We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program.Methods: Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350).Results: Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%), Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality.Conclusions: Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.

BACKGROUND:Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement.METHODS:All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post-PHTLS data by chi 2 analysis with a p value < or = 0.05 being considered statistically significant.RESULTS:The frequency (%) increased in the post-PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post-PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%).CONCLUSIONS:Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS.