The major trauma management study: an analysis of the efficacy of current trauma care.

BACKGROUND: An audit of the management and outcome of major trauma patients was carried out to determine ways in which the system of care may be improved. METHODS: The Major Trauma Management Study (MTMS) collected data prospectively on all consecutively admitted major trauma patients at eight major hospitals during a 12-month period. Outcome was studied using trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT) analyses, as well as a preventable outcome analysis, which looked at survivors with complications or with a Glasgow Coma Score < 15 on discharge from hospital, as well as studying deaths. RESULTS: The group of 859 patients was more severely injured than most described previously, with a mortality of 14.8% and a mean injury severity score of 19.8. Formal ASCOT analysis indicated 2.25% fewer survivors than would be predicted by Major Trauma Outcome Study norms. Extrapolating the TRISS and ASCOT process to include those patients with missing data, and then comparing groups of matched severity with the norms, gave no statistically different outcome in the MTMS group of patients. Preventable outcome analysis revealed rates of preventable and potentially preventable (P/PP) outcomes of 32% among deaths and 8% among survivors. The types of management deficiencies responsible for P/PP outcomes are identified. CONCLUSIONS: The points of deficiency in a system of care have been identified, and the development of an integrated trauma system in Victoria, based upon these facts, is recommended. Children, the elderly, patients with head injuries and patients being transferred between hospitals would benefit from improvements to the system of care. The calculation of efficacy rate (0.95 for the MTMS patients) is recommended to accurately assess the system of care. Preventable Outcome Analysis is more relevant to auditing a system of trauma care in detail, than is ASCOT or TRISS. The MTMS has refined and defined the process so that it is reproducible in further comparative studies.

Perfusion patterns during temporal lobe seizures: relationship to surgical outcome.

We sought to determine whether patterns of ictal hyperfusion demonstrated using [99mTC]HMPAO (hexamethylpropylene amine oxime) single photon emission computed tomography (SPECT) predict outcome of temporal lobectomy; in particular, whether the more extensive patterns of ictal hyperperfusion are associated with poor outcome. We studied 63 patients who had ictal SPECT studies prior to temporal lobectomy. Hyperperfusion on ictal SPECT scans was lateralized, and classified into: (i) 'typical', (ii) 'typical with posterior extension', (iii) 'bilateral' and (iv) 'atypical' patterns. Outcome (minimum of 2 years follow-up) was classified as either seizure free, or not seizure free. Actuarial analysis was used to test the relationship of SPECT patterns with outcome. There were 35 cases with the typical ictal SPECT pattern, 13 posterior, nine bilateral and six atypical cases. The atypical pattern was associated with lack of pathology in the surgical specimen. Outcome was similar for the typical, posterior and bilateral with 60%, 69% and 67% seizure free, respectively. In contrast, the atypical group had a worse outcome with only 33% seizure free. Actuarial analysis showed a significant difference in outcome between patients with the typical pattern, and patients with the atypical pattern (P = 0.04). We conclude that extended patterns of ictal perfusion in temporal lobe epilepsy do not predict poor outcome, indicating that extended hyperperfusion probably represents seizure propagation pathways rather than intrinsically epileptogenic tissue. Atypical patterns of hyperperfusion are associated with poor outcome and may indicate diffuse or extra-temporal epileptogenicity.

Preoperative MRI predicts outcome of temporal lobectomy: an actuarial analysis.

We used actuarial methods to study outcome after temporal lobectomy in 135 consecutive patients classified into subgroups according to preoperative MRI findings. Sixty months after surgery, 69% of patients with foreign tissue lesions, 50% with hippocampal sclerosis, and 21% with normal MRIs had no postoperative seizures. An eventual seizure-free state of 2 years or more, whether the patient was seizure-free since surgery or not, was achieved by 80% of patients with foreign tissue lesions, 62% of those with hippocampal sclerosis, and 36% of those with normal MRIs. Outcome was worse in those with normal MRIs than in the other two groups. Early postoperative seizures with later remission (the "running down" phenomenon) occurred in all groups. Late seizure recurrence was present only in the hippocampal sclerosis group. These data show that preoperative MRI is a useful predictor of outcome and that actuarial analysis provides insight into different longitudinal patterns of outcome in MRI subgroups. This information can now be used in preoperative counseling.

Temporal lobectomy for epilepsy - complicationsin 200 patients.

At the Austin Hospital, Melbourne, Australia, 200 consecutive temporal lobectomies were performed for refractorycomplex partial seizures between 1969 and 1991 as part of its Comprehensive Epilepsy Program. The complications of this retrospective series are reported. There were no 30-day postoperative deaths but there were 6 late deaths. Complications are divided into 'major' if permanent and/or severe or 'minor' if temporary or not severe. Complications included hemiparesis (2% major, 1% minor), visual field defect (3% major, 18. 5% minor), dysphasia (96 dominant resections - 0% major, 5. 5% minor), memory impairment (1 % major, 9. 5% minor); intracranial infection (2% major, 0% minor), and miscellaneous (11 % minor). The mechanisms of the complications are discussed. Temporal lobectomy for the treatment of epilepsy can be performed with a low morbidity.

Concurrent adjacent meningioma and astrocytoma: a report of three cases and review of the literature.

Three patients presenting with an adjacent meningioma and astrocytoma are described. A review of the literature discusses several modes of neuroimaging and the difficulties in diagnosing simultaneous adjacent tumors. Aspects of the pathology and etiology of these tumors are also reviewed.

The effectiveness of bicyclist helmets: a study of 1710 casualties.

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.

Craniotomy and thoracotomy for non-small cell carcinoma of the lung with cerebral metastasis.

Twenty patients with non-small cell carcinoma of the lung who had cerebral metastasis, were treated by craniotomy and thoracotomy. Eighteen of these patients had a solitary metastasis and all were treated as curable. Ten patients presented with synchronous lung and brain disease. Of the remaining 10, nine initially presented with the lung tumour, which was treated first. There was a zero operative mortality rate and median survival was 12 months with reasonable quality of life for this time.

Systemic hypovolemia after subarachnoid hemorrhage.

Two patients who had suffered subrachnoid hemorrhage were subjected to intensive monitoring of parameters of circulating blood flow, cardiovascular dynamics, and fluid and electrolyte balance. Among the parameters studied were red cell volume, plasma volume, and total blood volume, cardiac output, and central venous and pulmonary capillary wedge pressures. Both patients experienced acute neurological deterioration during the study. Red cell volume fell in a premonitory fashion prior to neurological deterioration in both, and in one patient plasma volume and total blood volume decreased by almost 50% in the 5 days prior to neurological deterioration. Central venous and pulmonary capillary wedge pressures fell initially but did not predict the deterioration. Systemic vascular resistance fell prior to clinical deterioration in one patient following ventriculoperitoneal shunting, and in the other following craniotomy and subarachnoid drainage. The falls in systemic vascular resistance may have caused shunting of cardiac output away from the compromised cerebral circulation, thereby triggering neurological deterioration.

Intraventricular infusion of Dopamine in Parkinson's disease.

A patient with severe end-stage Parkinson's disease and troublesome fluctuations in motor function was treated with a long-term intraventricular infusion of dopamine. There was modest improvement in speech and mentation and there was smoother control of motor symptoms that was superior to that achieved by conventional oral medications.

The radionuclide assessment of a system for slow intrathecal infusion of drugs.

The authors describe a new radionuclide method for assessing the functional integrity of slow intrathecal infusion devices. Approximately 11 mCi (400 MBq) of Tc-99m DTPA is injected into the pump chamber. Early and delayed imaging of the pump, tubing, and spinal cerebrospinal fluid space is performed on a digital large-field-of-view gamma camera. The digitally displayed images are then reviewed by adjustment of the grey scale window. Four patients have had eight studies and in each case the result has been confirmed by surgical exploration or by clinical response to change in therapy.

Timing of surgery for cerebral aneurysms: a plea for early referral.

Two groups of patients with aneurysmal subarachnoid haemorrhages--111 patients who underwent surgery within three days of haemorrhage, and 203 patients who underwent operations four or more days after the haemorrhage--were compared. No significant differences were found in outcome between the two groups. This indicates that early operation, which has the advantage of minimizing the risk of recurrent haemorrhage, is safe. The importance of the early diagnosis of subarachnoid haemorrhage and of an urgent referral for neurosurgical management is stressed.

Long term intrathecal administration of morphine: a comparison of bolus injection via reservoir with continuous infusion by implanted pump.

Twenty-six cases of chronic intrathecal morphine administration are described: 19 cases utilizing the Spinalgesic injectable subcutaneous reservoir and 7 cases utilizing the Infusaid implanted infusion pump. In 25 cases, the morphine was delivered into the spinal subarachnoid space, and in 1 case of thalamic pain it was delivered into the temporal horn of the ipsilateral cerebral ventricle. The average duration of usage of the system was 132 days. The efficacy of the method was excellent: 23 of 26 patients used no other analgesics or only minor ones such as aspirin, paracetamol, or dextropropoxyphene. The complication rate was low, with no infections under the author's care, and only 4 catheter blockages (1 by tumor). There have been no complications in the 7 patients with implanted pumps. From this experience, the author concludes that the implanted pump is now the method of choice in all patients who can afford it and for whom the life expectancy outside an institution is in excess of 60 days. A special and relatively absolute indication for the pump is the situation of pain in the arm, head, or neck areas, in which case the constant morphine levels likely to be achieved with the pump may prevent failure of the method due to intractable nausea or emesis. The subcutaneous reservoir is otherwise to be preferred if the patient's disease is progressing rapidly, if the patient is already institutionalized and likely to remain so, or where the cost of the implanted pump would cause hardship. Either method of delivery of morphine to the subarachnoid space can provide incomparable analgesia without clouding of consciousness, with a very low complication rate.

Achievement levels and mental health in medical students: a Monash University study.

An extensive battery of multi-choice psychology tests was administered to Monash Unversity medical students in 1975. Respondents were classified by sex, year and achievement level. Significant differences in parameters of psychological adaptation were detected when students in the three different achievement groups were compared. In general, the low achievers were more depressed and anxious, and less extroverted and empathic than their colleagues. In addition, their own assessment of their mental health was lower than that of their colleagues. They also tended to study less actively, were more prone to avoid the study of core material and derived less gratification overall from the medical course. It is suggested that underachievement in medical students is a danger signal connoting psychological difficulties and that under-achievers constitute a potentially under-counselled group. Counselling facilities should be sufficiently comprehensive to deal with the problems outlined as it is unlikely that this particular set of observations is unique to the group studied who happened to be medical students. The lesson is there for all faculties.