Context Prehospital hypertonic saline (HTS) resuscitation of patients with traumatic brain injury (TBI) may increase survival but whether HTS improves neurological outcomes is unknown.Objective To determine whether prehospital resuscitation with intravenous HTS improves long-term neurological outcome in patients with severe TBI compared with resuscitation with conventional fluids.Design, Setting, and Patients Double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic blood pressure, <100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia.Interventions Patients were randomly assigned to receive a rapid intravenous infusion of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls) in addition to conventional intravenous fluid and resuscitation protocols administered by paramedics. Treatment allocation was concealed.Main Outcome Measure Neurological function at 6 months, measured by the extended Glasgow Outcome Score (GOSE).Results Primary outcomes were obtained in 226 (99%) of 229 patients enrolled. Baseline characteristics of the groups were equivalent. At hospital admission, the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for controls (P<.001). The proportion of patients surviving to hospital discharge was similar in both groups (n =63 [55%] for HTS group and n =57 [50%] for controls; P=32); at 6 months, survival rates were n =62 (55%) in the HTS group and n =53 (47%) in the control group (P=.23). At 6 months, the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6) in the control group (P=.45). There was no significant difference between the groups in favorable outcomes (moderate disability and good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval, 0.76-1.30; P=.96) or in any other measure of postinjury neurological function.Conclusion In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.

BACKGROUND Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999. METHODS The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records. RESULTS The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units. CONCLUSION Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

BACKGROUND:The aim was to identify organizational and clinical errors in the management of road traffic fatalities and to use this information to improve Victoria's trauma care system.METHODS:A multidisciplinary committee evaluated the complete ambulance, hospital and autopsy records of 559 consecutive road traffic fatalities, who were alive on arrival of ambulance services, in five substantial time periods between 1992 and 1998. Patients who survived more than 30 days were excluded. Errors or inadequacies in each phase of management, including those contributing to death, were identified and an assessment was made of the potential preventability of death.RESULTS:Findings between 1992 and 1998 were similar. In 1998, 1672 problems were identified in 110 deaths with 1024 (61 per cent) contributing to death. Eight hundred and forty-two (50 per cent) of the total problems occurred in the emergency department. There were frequent problems in initial patient reception and medical consultation, resuscitation, investigation and assessment (especially of the abdomen and head), and in transfer to the operating theatre or to a higher-level hospital. Victoria's combined preventable and potentially preventable death rate has been unchanged between 1992 and 1998 (34-38 per cent).CONCLUSION:The problems identified led to a Ministerial Taskforce on Trauma and Emergency Services in Victoria as a consequence of which a new trauma system is now being implemented.

BACKGROUND:Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria has identified deficiencies and errors in the management of 559 road traffic fatalities in which the patients were alive on arrival of ambulance services. The Committee also assessed the preventability of deaths. Reproducibility of results using its methodology has been shown to be statistically significant. The Committee's findings and recommendations, the latter made in association with the learned Colleges and specialist Societies, led to the establishment of a Ministerial Taskforce on Trauma and Emergency Services. As a consequence, in 2000, a new trauma care system will be implemented in Victoria. This paper presents a case example demonstrating the Committee's methodology.METHODS:The Committee has two 12 member multidisciplinary evaluative panels. A retrospective evaluation was made of the complete ambulance, hospital and autopsy records of eligible fatalities. The clinical and pathological findings were analysed using a comprehensive data proforma, a narrative summary and the complete records. Resulting multidisciplinary discussion problems were identified and the potential preventability of death was assessed.RESULTS:In the present case example the Committee identified 16 management deficiencies of which 11 were assessed as having contributed to the patient's death; the death, however, was judged to be non-preventable.CONCLUSION:The presentation of this example demonstrating the Committee's methodology may be of assistance to hospital medical staff undertaking their own major trauma audit.

Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) has examined the medical management of patients who died following motor vehicle accidents. Three hundred and fifty-five fatalities with head injury occurring between 1 July, 1992 and 31 December 1997 were assessed by the CCRTF. They represented 79% of the total 449 fatalities examined by the Committee. Following examination of the complete medical records and multidisciplinary discussion, the Committee considered 237 (67%) of the 355 neurotrauma deaths to be non-preventable, 105 (30%) potentially preventable and 13 (4%) preventable. The present analysis excludes the non-preventable deaths in order to focus on preventable factors. Problems identified in the 118 patients pre-hospital included: no intubation; prolonged scene time; and no intravenous access; in 139 emergency room attendances: inappropriate reception including delay in arrival of a consultant, no neurosurgical consultation, no CT scan of the head, inadequate blood gases and oxygen monitoring, inadequate fluid resuscitation, delayed respiratory resuscitation and delayed dispatch to the operating room; in 111 operating room visits: no ICP monitoring, inadequate fluid administration and inappropriate anaesthetic technique; and in 90 intensive care unit admissions: no ICP monitoring. Overall, 1745 individual problems in the various areas of care were identified, of which 1104 (63%) were judged to have contributed to death. Improved delivery and quality of trauma care could reduce the identified problems in emergency services and clinical management. Basic principles of trauma management remain the most important means of reducing morbidity and death following road trauma. The leadership role of the neurosurgeon in neurotrauma care is emphasised.

Objective: To evaluate the management of severe trauma in intensive care, high dependency and general surgical wards of Victorian hospitals. Design: Retrospective case review by multidisciplinary committees. Subjects: The first 256 people who died from road traffic accidents who were alive on the arrival of emergency services between 1 July 1992 and 30 June 1994. Main outcome measures: (1) Severity of injury according to clinical diagnosis, autopsy findings and recognised trauma-scoring methods; (2) errors in management, identified as contributing or not contributing to the cause of death, and categorised as "management", "system", "diagnostic" or "technique" errors; Result-Most patients (61%) were admitted to an intensive care unit (ICU), and 19.5% were admitted to high dependency or general surgical wards. Of 2187 errors of care identified, 11.8% occurred in ICU and 6.7% in wards,with the remainder occurring during the earlier phases of care. Most errors were classified as management errors (82% of ICU errors and 88% of ward errors). Fifty-two per cent of ICU errors and 71% of ward errors were judged to contribute to the patient's death. Conclusions: A significant number of errors of trauma management occur in the intensive care and general surgical ward. Improvement in late trauma care may reduce the number of preventable trauma deaths.

understanding of the pathophysiology of disease that defines (and isolates) CMs, but also opens a window of opportunity for successful treatment for some patients. With such high proportions of the population using CMs, specific actions need to be taken. Appropriate structures and mechanisms that reflect the healthcare practices of the community need to be identifiable in government agencies and policies that serve that community. In Australia, no government agency reflects in its structure the high level of use of CM. Consumers deserve support both in terms of statutory regulation of practice where required, and increased relevant research. Applying the principles of evidence-based medicine will bring scientific rigour to the field of CM. There is no conflict here CM has always had a clinicaloutcomes focus. The medical profession also needs to become more familiar with CM practices. Communication rates across practitioner groups are still too low.7,15 We need to develop less adversarial, more collegial relationships, which can be done through better education. To the scientist, the evidence in support of CM may be weak, but to the patient the instinctive search for a remedy that brings relief knows no such intellectual boundaries. This is a search ruled by pragmatism. The searches are relatively new because so many doors have recently been opened by globalisation (eg, traditional Chinese medicine) and increased public access to health information, coupled with a sensitivity towards traditional cultural practices. Medical practitioners, other healthcare professionals and patients are exploring CM for good reasons.

Objectives Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria, Australia, has identified problems including those contributing to death and the potential preventability of deaths in road fatalities who survived until at least the arrival of ambulance services. The present analysis examines the outcomes at a Level I trauma center compared with other hospital groups in Victoria. Methods Between 1992 and 1994, 257 consecutive eligible fatalities were evaluated. Problems in management and preventable deaths were identified at the trauma center (TC) and in pooled data from other hospital groups, i.e., specialist teaching (Level II), other metropolitan (Level III), large regional (Level III), and small regional hospitals. Results Mean problems identified and those contributing to death (controlled for the number of areas of care), were less frequent at TC (1.7 and 0.6) than at other hospital groups (specialist teaching, 1.9 and 1.1*; metropolitan, 3.1* and 1.6*; large regional, 3.8* and 1.8*; small regional, 5.1* and 2.6*) (*p < 0.05 compared with TC). Preventable and potentially preventable deaths were also less common at TC (20%) than at the other hospital groups (specialist teaching, 40%*; metropolitan, 41%*; large regional, 53%*; small regional, 62%*) (*p < 0.05 compared with TC). When a Trauma and Injury Severity Score of 75% or more was used to define preventable death, a similar trend was identified. Conclusion Management of patients with major trauma at a Level I trauma center was associated with fewer problems contributing to death and fewer preventable and potentially preventable deaths than at the different hospital groups. A trauma system in Victoria, including bypass of major trauma patients to designated hospitals with 24-hour trauma services, is likely to decrease the frequency of problems, including the preventable death rates.

BACKGROUND:Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria has identified problems in the management of traffic fatalities. Its two evaluative committees have additionally assessed the potential preventability of death. Previous studies have shown only poor to fair reproducibility of death judgments. METHODS:Problems in the management of 60 consecutive road traffic fatalities and the potential preventability of death were independently evaluated by the two committees. Inter-rater and inter-committee concordance were analyzed using the kappa statistic. RESULTS:Reproducibility was high. Inter-committee agreement on nonpreventable, potentially preventable, and preventable death judgments was high (kappa = 0.73, 95% confidence interval = 0.57-0.89). Agreement within the two evaluative committees was also high (average weighted kappa = 0.73 and 0.74). There was good agreement between committees on problems identified, including those contributing to death. CONCLUSION:The high kappa concordance on preventable death judgments and the agreement on problem identification supports the reproducibility of the methodology used.

After a decade of promotion and education, legislation for mandatory helmet wearing by bicyclists in Victoria was introduced on 1 July 1990. The legislation was a world first. Comparison of 1710 bicyclist casualties wearing and not wearing helmets has demonstrated that wearing helmets certified to the Australian Standard reduces the head injury risk by at least 39% and lessens head injury severity. Simulated impact testing of helmets has shown that they provide protection in most impacts including collisions involving a motor vehicle. Legislation for mandatory helmet wearing in Victoria has led to increased wearing rates and marked reductions in bicyclist fatalities and head injuries. The Victorian experience gives substantial support to the introduction of legislation for mandatory helmet wearing by bicyclists.

Audit is the evaluation of patient care. The care of the injured patient commences at the accident scene and involves prehospital triage and management, emergency hospital assessment and resuscitation, diagnostic and therapeutic interventions, operative surgery, intensive care unit management, acute hospital care and rehabilitation. Audit assesses the delivery of trauma care and clinical management and through identification of inadequacies facilitates the introduction of appropriate improvements. Both the American National Academy of Sciences--National Research Council and the Australian National Health & Medical Research Council have recommended the establishment of an audit process to evaluate the quality of trauma management and to obtain quality assurance. They have advised that this process would be assisted by the development of regional trauma registries and a uniform approach to the grading of injuries. Reduction in the preventable death rate, frequency of complications and duration of hospitalization has followed audits as a result of changes in the organization and quality of trauma care. In the United States, for example, the preventable death rate after injury was reduced from 35 to 15% in Orange County, California and from 14 to 3% in San Diego County, California. Studies from Great Britain. The Netherlands, Canada, Australia and elsewhere have further supported the view that trauma audit modifies practice leading to reductions in mortality and morbidity.

Objective: To quantify any risk for colorectal cancer in first-degree relatives of patients with common colorectal cancer and to define possible markers for increased risk.Design: Case-control family study.Patients: Relatives of colorectal cancer patients and of matched control patients from a one-surgeon practice.Methods: Family medical histories were obtained for 7493 first-degree relatives and 1015 spouses of 523 case-control pairs. Reported diagnoses of colorectal cancer in relatives were verified in 79% of instances.Results: By case-control analysis, the odds ratio was 1.8 (95% CI, 1.2 to 2.7) for one and 5.7 (CI, 1.7 to 19.3) for two affected relatives. By matched analysis of risk in relatives, the increased risk to parents and siblings was 2.1 times greater for case patients than for control patients (CI, 1.4 to 3.1); 3.7 times greater (CI, 1.5 to 9.1 ) with case patients diagnosed before 45; and 1.8 times greater (CI, 1.2 to 2.9) with case patients diagnosed at 45 years or older; and was independent of gender, type of relative, site of cancer, and type of cancer (single or multiple). The cumulative incidence, among first-degree relatives was greater for case patients than for control patients (P < 0.001), and in case patients, greater for those diagnosed before 55 years of age (P < 0.001). The cumulative incidence (+/- S.E.) to age 80 was 11.1% +/- 1.3%, 7.3% +/- 0.8%, and 4.4% +/-1.0% among relatives of case patients diagnosed before age 45 years, between 45 and 54 years, and at 55 years or older, respectively, and was 2.4% +/- 0.6% in relatives of control patients.Conclusions: First-degree relatives of patients with common colorectal cancer have an increased risk for colorectal cancer. This risk is greater if diagnosis was at an early age and is greater when other first-degree relatives are affected. This increased risk should be considered when formulating screening strategies.

During the 1980s, a sustained campaign increased the rates of helmet use of Victorian bicyclists. The efficacy of helmet use was evaluated by comparison of crashes and injuries (AIS-1985) in 366 helmeted (261 Australian Standard approved and 105 non-approved) and 1344 unhelmeted casualties treated from 1987 through 1989 at Melbourne and Geelong hospitals or dying before hospitalization. Head injury (HI) occurred in 21.1% of wearers of approved helmets and in 34.8% of non-wearers (p < 0.001). The AIS scores were decreased for wearers of approved helmets (p < 0.001), face injuries were reduced (p < 0.01), and extremity/pelvic girdle injuries increased (p < 0.001) and the overall risk of HI was reduced by at least 39% and face injury by 28%. When casualties with dislodged helmets were excluded, HI was reduced 45% by approved helmets. Head injury reduction by helmets, although substantial, was less than that found in a similar study in Seattle, Washington.

The results of a comparative study of the injury profiles of Victorian motorcyclist and bicyclist casualties were used by the Royal Australasian College of Surgeons in initiating a state-wide campaign to promote the wearing of approved safety helmets by Victorian bicyclists and to obtain the necessary legislation whereby such wearing would become compulsory. Bicyclist casualties had sustained more frequent and severe head injuries than motorcyclist casualties although the latter had sustained overall more severe body injuries. Increases in voluntary helmet wearing rates and reductions in costs preceded the introduction in July, 1990 in Victoria of compulsory safety helmet wearing by bicyclists. Sixty-four helmets obtained during a study of more than 1,700 Victorian bicyclists wearing and not wearing helmets were evaluated for performance by impact severity testing and findings related to head injury occurrence. Sixteen helmets sustained more than one impact during the accident. All casualties who sustained a severe head injury (Abbreviated Injury Scale ≥ 4) were involved in a collision with a motor vehicle and subjected to more than one impact to the head/helmet and/or the helmet had come off during the accident. Most impacts occurred below the current test lines of Australian and United States standards. Ten percent of impacts were more severe than required in performance standards. Recommendations are made for improvements in the current standard.

Australian and New Zealand Journal of SurgeryVolume 62, Issue 11 p. 841-848 BREAST CARCINOMA IN SITU F. T. McDermott, Corresponding Author F. T. McDermott Monash University Department of Surgery, Alfred Hospital, Prahran, Victoria, AustraliaMonash University, Department of Surgery, Alfred Hospital, Commercial Road, Prahran, Vic. 3181, Australia.Search for more papers by this author F. T. McDermott, Corresponding Author F. T. McDermott Monash University Department of Surgery, Alfred Hospital, Prahran, Victoria, AustraliaMonash University, Department of Surgery, Alfred Hospital, Commercial Road, Prahran, Vic. 3181, Australia.Search for more papers by this author First published: November 1992 https://doi.org/10.1111/j.1445-2197.1992.tb06936.xCitations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume62, Issue11November 1992Pages 841-848 RelatedInformation

A series of 908 cases of colonic carcinoma has been analysed to elucidate reasons for the poor prognosis in obstructing colonic cancer. Complete obstruction was present in 148 cases (16.3 per cent), 280 cases (30.8 per cent) had partial obstruction and 480 (52.8 per cent) presented without obstruction. There were fewer Dukes' A tumours in those with complete obstruction (P less than 0.005) and greater numbers of advanced tumours (P less than 0.0005) compared with those without obstruction. This is reflected in a lower curative resection rate of 50.7 per cent in those with obstruction compared with 70.6 per cent in those without obstruction (P less than 0.001). However, after curative resection there was no significant difference in the distribution of tumour stage. Patients with complete obstruction showed a higher incidence of recurrence (P less than 0.01) after curative resection, consequent to an increased incidence of local recurrence (P less than 0.02). Five-year cancer-specific survival for the total series was decreased from 59.1 per cent in patients without obstruction to 31.8 per cent in those with complete obstruction (P less than 0.001). After curative resection there was also a significant reduction in survival (P less than 0.001). It is concluded that completely obstructing colonic cancers are more aggressive than other colonic cancers.

This report emphasizes the importance of obtaining high-quality mammograms in patients with breast symptoms. An initial negative report in a 40-year-old woman with no palpable breast lump unfortunately was based upon inadequate films which, had they not been reviewed and repeat mammography been arranged, would have led to the patient being reassured mistakenly that no significant breast disease was present.